Provider Demographics
NPI:1568557296
Name:BOSARGE, KENNETH L (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:BOSARGE
Suffix:
Gender:M
Credentials:DC
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 2028
Mailing Address - Street 2:
Mailing Address - City:ESCATAWPA
Mailing Address - State:MS
Mailing Address - Zip Code:39552-2028
Mailing Address - Country:US
Mailing Address - Phone:228-475-6437
Mailing Address - Fax:228-474-1325
Practice Address - Street 1:7302D HIGHWAY 613
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-9312
Practice Address - Country:US
Practice Address - Phone:228-475-6437
Practice Address - Fax:228-474-1325
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS867111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5598580OtherAETNA
MS34300Medicare UPIN