Provider Demographics
NPI:1245309004
Name:BOGREN, TIMOTHY W (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:BOGREN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1508
Mailing Address - Country:US
Mailing Address - Phone:304-743-1261
Mailing Address - Fax:304-743-1899
Practice Address - Street 1:332 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1508
Practice Address - Country:US
Practice Address - Phone:304-743-1261
Practice Address - Fax:304-743-1899
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001711177OtherMT. ST. BCBS
WV0131934000Medicaid
WVB00756181Medicare PIN
WVU47764Medicare UPIN