Provider Demographics
NPI:1477095370
Name:BOSKOVICH, BROOKE KATHLEEN (RD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:KATHLEEN
Last Name:BOSKOVICH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:KATHLEEN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 8815
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-8815
Mailing Address - Country:US
Mailing Address - Phone:541-980-7659
Mailing Address - Fax:
Practice Address - Street 1:1750 NE NEFF RD
Practice Address - Street 2:GUEST HOUSE
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6111
Practice Address - Country:US
Practice Address - Phone:541-980-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10177805133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered