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NPI Code Detail

MEDICARE: RILEY JAY BOUCHARD

MEDICARE: RILEY JAY BOUCHARD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist05013568AIN

General Provider Information

NPI Number : 1255982922
Entity Type Code : Individual
Provider Name (Legal Business Name) : RILEY JAY BOUCHARD
Provider Business Mailing Address
First Line : 790 REMINGTON BLVD
Second Line :
City : BOLINGBROOK
State : IL
Zip : 60440-4909
Country : US
Telephone Number : 630-296-2222
Fax Number : 630-759-9510
Provider Business Practice Location Address
First Line : 4020 COLUMBUS AVE
Second Line :
City : ANDERSON
State : IN
Zip : 46013-5010
Country : US
Telephone Number : 765-641-7605
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/24/2019
Last Update Date : 09/24/2019

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