=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598264749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. KARL OLOF RIKARD BOERJESSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 03/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 LINCOLN AVE
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-220-3496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1168 CHERRY ST
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-220-3496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.013189
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------