Provider Demographics
NPI:1457608945
Name:BOGARD, RICHARD LAWRENCE (NPF)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LAWRENCE
Last Name:BOGARD
Suffix:
Gender:M
Credentials:NPF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11762 DE PALMA RD
Mailing Address - Street 2:SUITE 1 C PMB 57
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-4010
Mailing Address - Country:US
Mailing Address - Phone:951-258-1938
Mailing Address - Fax:
Practice Address - Street 1:3634 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2506
Practice Address - Country:US
Practice Address - Phone:951-341-8935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21270363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health