Provider Demographics
NPI:1336179225
Name:BOLTON, PHILIP L (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:L
Last Name:BOLTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S PROSPECT RD STE 5
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4907
Mailing Address - Country:US
Mailing Address - Phone:309-662-7788
Mailing Address - Fax:
Practice Address - Street 1:211 S PROSPECT RD STE 5
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4907
Practice Address - Country:US
Practice Address - Phone:309-662-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038-003600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL222730Medicare ID - Type Unspecified
ILU39823Medicare UPIN