Healthcare Provider Details

I. General information

NPI: 1316672462
Provider Name (Legal Business Name): BOFFO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 CHESWICK LN
HENRICO VA
23229-7661
US

IV. Provider business mailing address

313 CHESWICK LN
HENRICO VA
23229-7661
US

V. Phone/Fax

Practice location:
  • Phone: 804-396-0372
  • Fax:
Mailing address:
  • Phone: 804-396-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN M LANE
Title or Position: PRESIDENT
Credential: MD
Phone: 804-396-0372