MEDICARE: DR. KENNETH WILLIAM BODDIE M.D.

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	225400000X	Rehabilitation Practitioner	G40741	CA

General Provider Information

NPI Number	:	1225088230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH WILLIAM BODDIE M.D.

Provider Business Mailing Address
First Line	:	1215 S GRAMERCY PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-3638
Country	:	US
Telephone Number	:	213-387-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	639 S HAMPSHIRE AVE 2ND FLOOR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005
Country	:	US
Telephone Number	:	213-387-9400
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/09/2007

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