Basic Information
| Provider Information | |||||||||
| NPI: | 1003544750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOEKE | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 KNOX AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORTH AUGUSTA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298414022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438008345 | ||||||||
| FaxNumber: | 8438008346 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 KNOX AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORTH AUGUSTA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298414022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438008345 | ||||||||
| FaxNumber: | 8438008346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11462 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.