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General NPI Number Information
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NPI Number | 1851701668
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Entity Type | Individual
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Provider Name | DEMETRIOS BOBOLOS LAC
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Gender | Male
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Dates
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Enumeration Date | 05/01/2014
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Last Update Date | 05/01/2014
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Provider Practice Location Address
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Address Line | 512 W BURLINGTON AVE SUITE 104
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City | LA GRANGE
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State | IL
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Zip | 60525-2221
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Country | US
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Telephone | 708-469-7592
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Fax |
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Provider Business Mailing Address
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Address Line | 5757 N SHERIDAN RD 17D
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City | CHICAGO
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State | IL
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Zip | 60660-4746
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Country | US
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Telephone | 773-835-2626
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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 | 198.001145
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License Number State | IL
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