MEDICARE: MR. ANDREW DAVID BOEHNKE MS, ATC

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	2255A2300X	Athletic Trainer	0209	SD

General Provider Information

NPI Number	:	1649322942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW DAVID BOEHNKE MS, ATC

Provider Business Mailing Address
First Line	:	6905 W 68TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-8831
Country	:	US
Telephone Number	:	605-360-0231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 S GRANGE
Second Line	:	ELMEN CENTER
City	:	SIOUX FALLS
State	:	SD
Zip	:	57197-0002
Country	:	US
Telephone Number	:	605-274-4332
Fax Number	:	605-274-5298

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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