Provider Demographics
NPI:1437719937
Name:BOEHM, BRUCE WILLIAM JR
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WILLIAM
Last Name:BOEHM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-0287
Mailing Address - Country:US
Mailing Address - Phone:641-842-4618
Mailing Address - Fax:
Practice Address - Street 1:205 N IOWA ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2833
Practice Address - Country:US
Practice Address - Phone:641-842-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA630299320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness