Provider Demographics
NPI:1851701668
Name:BOBOLOS, DEMETRIOS (LAC)
Entity Type:Individual
Prefix:
First Name:DEMETRIOS
Middle Name:
Last Name:BOBOLOS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 N SHERIDAN RD
Mailing Address - Street 2:17D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4746
Mailing Address - Country:US
Mailing Address - Phone:773-835-2626
Mailing Address - Fax:
Practice Address - Street 1:512 W BURLINGTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2221
Practice Address - Country:US
Practice Address - Phone:708-469-7592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist