MEDICARE: TAVONA BOGGS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT008241	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT008241	OTHER	GA	STATE LISC NUMBER

General Provider Information

NPI Number	:	1043399884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAVONA BOGGS PT

Provider Business Mailing Address
First Line	:	5776 VILLAGE LOOP
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-7932
Country	:	US
Telephone Number	:	770-551-5261
Fax Number	:	770-551-5261

Provider Business Practice Location Address
First Line	:	2770 LENOX RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-6006
Country	:	US
Telephone Number	:	404-264-9553
Fax Number	:	404-266-2294

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	05/01/2008

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