=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568557296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH L. BOSARGE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7302D HIGHWAY 613
-----------------------------------------------------
City | MOSS POINT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39563-9312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-475-6437
-----------------------------------------------------
Fax | 228-474-1325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2028
-----------------------------------------------------
City | ESCATAWPA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39552-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-475-6437
-----------------------------------------------------
Fax | 228-474-1325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 867
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------