Healthcare Provider Details

I. General information

NPI: 1457767857
Provider Name (Legal Business Name): JOHN BJORN BOQUIST DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 WAUKEGAN RD
LAKE BLUFF IL
60044-1666
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 847-735-8104
  • Fax:
Mailing address:
  • Phone: 630-575-1916
  • Fax: 630-928-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-022047
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: