Provider Demographics
NPI:1477144772
Name:BODEN HEALTH NATIONAL GOUT CENTERS, LLC
Entity Type:Organization
Organization Name:BODEN HEALTH NATIONAL GOUT CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-508-0651
Mailing Address - Street 1:4 WEEMS LN # 128
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3602
Mailing Address - Country:US
Mailing Address - Phone:540-508-0651
Mailing Address - Fax:540-508-0841
Practice Address - Street 1:3038 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2637
Practice Address - Country:US
Practice Address - Phone:540-508-0651
Practice Address - Fax:540-508-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty