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General NPI Number Information
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NPI Number | 1225438252
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Entity Type | Individual
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Provider Name | MICHAEL JOSEPH BOEHKE ATC
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Gender | Male
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Dates
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Enumeration Date | 08/27/2014
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Last Update Date | 08/27/2014
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Provider Practice Location Address
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Address Line | 101 COLLEGE HILL DRIVE, BOX 2061
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City | PHILIPPI
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State | WV
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Zip | 26416
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Country | US
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Telephone | 304-457-6300
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Fax |
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Provider Business Mailing Address
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Address Line | BOX 2061, 101 COLLEGE HILL DRIVE
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City | PHILIPPI
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State | WV
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Zip | 26416
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Country | US
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Telephone | 304-457-6300
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001094
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License Number State | WV
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