Provider Demographics
NPI:1407343296
Name:BOGGS, LYDIA C
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:C
Last Name:BOGGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MARY STREET P.O. BOX 2361
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502
Mailing Address - Country:US
Mailing Address - Phone:912-550-3382
Mailing Address - Fax:912-287-6689
Practice Address - Street 1:1020 MARY ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-3849
Practice Address - Country:US
Practice Address - Phone:912-550-3382
Practice Address - Fax:912-287-6689
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid