Basic Information
| Provider Information | |||||||||
| NPI: | 1578997607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOEHM | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | SSB-6 | ||||||||
| Address2: | 400 E 3RD ST | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1904 SKY PARK DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417732999 | ||||||||
| FaxNumber: | 5417731874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2013 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12446 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT60727805 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 60351 | 01 | OR | PHYSICAL THERAPIST | OTHER | 1804 | 01 | ND | PHYSICAL THERAPIST | OTHER |