=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336520451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA MARIE BOGGS RT (R)(CT)
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2015
-----------------------------------------------------
Last Update Date | 06/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 S FROELICH LN
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61410-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-299-9138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 S FROELICH LN
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61410-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-299-9138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2471C3401X
-----------------------------------------------------
Taxonomy Name | Computed Tomography Radiologic Technologist
-----------------------------------------------------
License Number | 500493591
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------