Provider Demographics
NPI:1649645037
Name:BOEHMKE, REGHAN (MA, ATC)
Entity type:Individual
Prefix:MRS
First Name:REGHAN
Middle Name:
Last Name:BOEHMKE
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 WOOD DUCK LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3934
Mailing Address - Country:US
Mailing Address - Phone:843-992-9057
Mailing Address - Fax:
Practice Address - Street 1:4622 E PALMETTO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29502
Practice Address - Country:US
Practice Address - Phone:843-661-1358
Practice Address - Fax:843-661-4645
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer