MEDICARE: RICHARD BOM 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	2704	MN

General Provider Information

NPI Number	:	1689789554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD BOM PT

Provider Business Mailing Address
First Line	:	19540 VINE RIDGE RD
Second Line	:
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-9118
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	775 PRAIRIE CENTER DR
Second Line	:	#250
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7314
Country	:	US
Telephone Number	:	952-944-5314
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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