Healthcare Provider Details

I. General information

NPI: 1942803192
Provider Name (Legal Business Name): KENDRA L BOMGARDNER MOT, ORT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINGSBOROUGH SQ STE B
CHESAPEAKE VA
23320-4988
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0434
  • Fax: 757-547-0612
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119008823
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: