Healthcare Provider Details

I. General information

NPI: 1013062405
Provider Name (Legal Business Name): JACQUE ARLIN BOUTWELL JR. CFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 COUNTY RD 6 E
ELKHART IN
46514-7673
US

IV. Provider business mailing address

5146 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 574-214-7504
  • Fax: 574-262-3214
Mailing address:
  • Phone: 574-214-7504
  • Fax: 574-262-3214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: