Provider Demographics
NPI:1912365792
Name:BOMGARDNER, RICHARD (ATC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BOMGARDNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 N INWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2206
Mailing Address - Country:US
Mailing Address - Phone:316-978-5981
Mailing Address - Fax:316-978-5451
Practice Address - Street 1:1845 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260-0016
Practice Address - Country:US
Practice Address - Phone:316-978-5981
Practice Address - Fax:316-978-5451
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-004242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer