Provider Demographics
NPI:1780915595
Name:BOGGS, KENNETH (CO)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:BOGGS
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 W FARWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4515
Mailing Address - Country:US
Mailing Address - Phone:773-972-1136
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:SUITE 1764
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:132-238-2810
Practice Address - Fax:312-238-1932
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000065222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist