Provider Demographics
NPI:1063462828
Name:BOGDONOVICH, CHAD A (PT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:BOGDONOVICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604B NORTH DIVISION ST.
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:WI
Mailing Address - Zip Code:54421
Mailing Address - Country:US
Mailing Address - Phone:715-223-4060
Mailing Address - Fax:715-223-4032
Practice Address - Street 1:604B NORTH DIVISION ST
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421
Practice Address - Country:US
Practice Address - Phone:715-223-4060
Practice Address - Fax:715-223-4032
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6174024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist