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General NPI Number Information
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NPI Number | 1104049501
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Entity Type | Individual
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Provider Name | RICHARD BOEHM
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Gender | Male
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 17 E LANCASTER AVE
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City | ARDMORE
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State | PA
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Zip | 19003-2319
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Country | US
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Telephone | 610-645-0546
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Fax |
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Provider Business Mailing Address
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Address Line | 17 E LANCASTER AVE
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City | ARDMORE
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State | PA
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Zip | 19003-2319
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | NJ D-1242
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License Number State | NJ
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