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General NPI Number Information
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NPI Number | 1407258510
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Entity Type | Individual
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Provider Name | GENNADY BOLDETSKY
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Gender | Male
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Dates
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Enumeration Date | 09/19/2014
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Last Update Date | 09/19/2014
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Provider Practice Location Address
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Address Line | 1040 S MILWAUKEE AVE SUITE 100
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City | WHEELING
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State | IL
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Zip | 60090-6373
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Country | US
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Telephone | 847-366-9518
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Fax |
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Provider Business Mailing Address
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Address Line | 7975 N NORDICA AVE
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City | NILES
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State | IL
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Zip | 60714-3315
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Country | US
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Telephone | 847-366-9518
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 198001173
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License Number State | IL
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