Healthcare Provider Details

I. General information

NPI: 1437534427
Provider Name (Legal Business Name): BOLEVIKA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6157 N SHERIDAN RD APT 17K
CHICAGO IL
60660-3089
US

IV. Provider business mailing address

6157 N SHERIDAN RD APT 17K
CHICAGO IL
60660-3089
US

V. Phone/Fax

Practice location:
  • Phone: 773-510-5063
  • Fax:
Mailing address:
  • Phone: 773-510-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number2380000087
License Number StateIL

VIII. Authorized Official

Name: BOHDAN KONTSEVYY
Title or Position: PRESIDENT
Credential: AS
Phone: 773-510-5063