Provider Demographics
NPI:1942731922
Name:BOUTCHEKO, EMMANUEL
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:BOUTCHEKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17709 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2063
Mailing Address - Country:US
Mailing Address - Phone:708-307-3854
Mailing Address - Fax:
Practice Address - Street 1:17709 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2063
Practice Address - Country:US
Practice Address - Phone:708-307-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.105922164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043.105922OtherLICENSE PRACTICAL NURSE