Healthcare Provider Details

I. General information

NPI: 1043289895
Provider Name (Legal Business Name): BOGEROSA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 ASH AVENUE
GLEN ULLIN ND
58632-0065
US

IV. Provider business mailing address

4729 AMBERGLOW DR
BISMARCK ND
58503-8846
US

V. Phone/Fax

Practice location:
  • Phone: 701-348-9175
  • Fax:
Mailing address:
  • Phone: 701-426-7095
  • Fax: 701-250-0182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberND 534
License Number StateND

VIII. Authorized Official

Name: MR. MARK W BOGERT
Title or Position: OWNER
Credential: PT
Phone: 701-426-7095