Provider Demographics
NPI:1629337829
Name:BOSSHARDT, GREG MILO (DC)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:MILO
Last Name:BOSSHARDT
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 1:320 S 50 W
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-4023
Mailing Address - Country:US
Mailing Address - Phone:435-283-7955
Mailing Address - Fax:
Practice Address - Street 1:320 S 50 W
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-4023
Practice Address - Country:US
Practice Address - Phone:435-283-7955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012004603111N00000X
UT8303581-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor