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General NPI Number Information
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NPI Number | 1699210708
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Entity Type | Organization
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Legal Business Name | LIVE BOLD
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 33 W DELAWARE PL
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City | CHICAGO
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State | IL
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Zip | 60610-8115
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Country | US
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Telephone | 978-877-0781
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Fax |
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Provider Business Mailing Address
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Address Line | 33 W DELAWARE PLACE
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City | CHICAGO
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State | IL
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Zip | 60610
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALLISON BLOOD
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Credential |
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Telephone | 978-877-0781
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 209009533
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License Number State | IL
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