MEDICARE: DR. PHILIP L. BOLTON D.C.

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
1	111N00000X	Chiropractor	0038-003600	IL

General Provider Information

NPI Number	:	1336179225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP L. BOLTON D.C.

Provider Business Mailing Address
First Line	:	211 S PROSPECT RD STE 5
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-4907
Country	:	US
Telephone Number	:	309-662-7788
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 S PROSPECT RD STE 5
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-4907
Country	:	US
Telephone Number	:	309-662-7788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	07/08/2007

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