MEDICARE: BOLES CHIROPRACTIC CENTRE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3248	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1952460396	OTHER		INDIVIDUAL NPI

General Provider Information

NPI Number	:	1801115027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLES CHIROPRACTIC CENTRE, LLC

Provider Business Mailing Address
First Line	:	12201 W NORTH AVE
Second Line	:	STE 204
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2061
Country	:	US
Telephone Number	:	414-476-0111
Fax Number	:	414-476-0832

Provider Business Practice Location Address
First Line	:	12201 W NORTH AVENUE
Second Line	:	STE 204
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2061
Country	:	US
Telephone Number	:	414-476-0111
Fax Number	:	414-476-0832

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELENA C BOLES
Credential	:	D.C.
Telephone Number	:	414-476-0111

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	06/02/2010

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