Provider Demographics
NPI:1629028626
Name:XU, BO (CMD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:
Last Name:XU
Suffix:
Gender:M
Credentials:CMD
Other - Prefix:DR
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:XU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMD
Mailing Address - Street 1:1307 BLUEJAY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5423
Mailing Address - Country:US
Mailing Address - Phone:815-685-6497
Mailing Address - Fax:815-230-1851
Practice Address - Street 1:1307 BLUEJAY LN
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-5423
Practice Address - Country:US
Practice Address - Phone:815-685-6497
Practice Address - Fax:815-230-1851
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL55343813133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist