Provider Demographics
NPI:1043289895
Name:BOGEROSA INC.
Entity Type:Organization
Organization Name:BOGEROSA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOGERT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:701-426-7095
Mailing Address - Street 1:4729 AMBERGLOW DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8846
Mailing Address - Country:US
Mailing Address - Phone:701-426-7095
Mailing Address - Fax:701-250-0182
Practice Address - Street 1:602 ASH AVENUE
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58632-0065
Practice Address - Country:US
Practice Address - Phone:701-348-9175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND 534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55000Medicaid
ND24439OtherBLUE CROSS/BLUE SHIELD OF
N711341Medicare PIN