Provider Demographics
NPI:1255684379
Name:BOGGESS, BRADLEY RAY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RAY
Last Name:BOGGESS
Suffix:
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 1:6301 N. LUCERNE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-3105
Mailing Address - Country:US
Mailing Address - Phone:816-569-1802
Mailing Address - Fax:816-569-2099
Practice Address - Street 1:6301 N. LUCERNE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-3105
Practice Address - Country:US
Practice Address - Phone:816-569-1802
Practice Address - Fax:816-569-2099
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009004521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist