Healthcare Provider Details

I. General information

NPI: 1407258510
Provider Name (Legal Business Name): GENNADY BOLDETSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 S MILWAUKEE AVE SUITE 100
WHEELING IL
60090-6373
US

IV. Provider business mailing address

7975 N NORDICA AVE
NILES IL
60714-3315
US

V. Phone/Fax

Practice location:
  • Phone: 847-366-9518
  • Fax:
Mailing address:
  • Phone: 847-366-9518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001173
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: