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General NPI Number Information
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NPI Number | 1356584932
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Entity Type | Organization
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Legal Business Name | BOHO PAIN MANAGEMENT AND REHABILITATION LLC
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 04/15/2009
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Provider Practice Location Address
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Address Line | 3701 DURAND AVE
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City | RACINE
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State | WI
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Zip | 53405-4458
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Country | US
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Telephone | 262-497-8798
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Fax | 262-554-6354
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Provider Business Mailing Address
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Address Line | 3715 LINDA LN
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City | RACINE
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State | WI
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Zip | 53405-4827
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Country | US
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Telephone | 262-554-9465
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Fax | 262-554-6354
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Authorized Official
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Title or Position | PRESIDENT AND OWNER
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Name | DAVID JOHN BOHO
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Credential | O.T.R.
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Telephone | 262-497-8798
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | 919-026
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License Number State | WI
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