Provider Demographics
NPI:1912135534
Name:BOGLE, RICKIE MACKENZIE (LMT)
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:MACKENZIE
Last Name:BOGLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2632
Mailing Address - Country:US
Mailing Address - Phone:207-773-5778
Mailing Address - Fax:207-773-5773
Practice Address - Street 1:218 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2632
Practice Address - Country:US
Practice Address - Phone:207-773-5778
Practice Address - Fax:207-773-5773
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3944171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor