Healthcare Provider Details

I. General information

NPI: 1568557296
Provider Name (Legal Business Name): KENNETH L. BOSARGE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7302D HIGHWAY 613
MOSS POINT MS
39563-9312
US

IV. Provider business mailing address

PO BOX 2028
ESCATAWPA MS
39552-2028
US

V. Phone/Fax

Practice location:
  • Phone: 228-475-6437
  • Fax: 228-474-1325
Mailing address:
  • Phone: 228-475-6437
  • Fax: 228-474-1325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number867
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: