Provider Demographics
NPI:1720637671
Name:BODDIE, LARONDA
Entity type:Individual
Prefix:
First Name:LARONDA
Middle Name:
Last Name:BODDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 MOSS GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-7454
Mailing Address - Country:US
Mailing Address - Phone:843-708-0342
Mailing Address - Fax:
Practice Address - Street 1:1094 MOSS GROVE DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-7454
Practice Address - Country:US
Practice Address - Phone:843-708-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider