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General NPI Number Information
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NPI Number | 1740059260
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Entity Type | Individual
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Provider Name | MR. TYLER JAMES BOUTSIKAKIS
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Gender | Male
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Dates
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Enumeration Date | 12/26/2023
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Last Update Date | 12/26/2023
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Provider Practice Location Address
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Address Line | 4 CEDAR RIDGE DR STE A
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City | LAKE IN THE HILLS
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State | IL
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Zip | 60156-4712
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Country | US
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Telephone | 847-458-2527
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Fax |
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Provider Business Mailing Address
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Address Line | 131 ENTERPRISE RD
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City | JOHNSTOWN
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State | NY
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Zip | 12095-3326
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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 |
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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 | 237700000X
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Taxonomy Name | Hearing Instrument Specialist
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License Number | 3553
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License Number State | IL
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