Provider Demographics
NPI:1649455502
Name:BOUMA, JOHN NOLAN (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:NOLAN
Last Name:BOUMA
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 1:419 CENTER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1625
Mailing Address - Country:US
Mailing Address - Phone:847-543-1055
Mailing Address - Fax:847-543-8648
Practice Address - Street 1:419 CENTER ST
Practice Address - Street 2:SUITE B
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1625
Practice Address - Country:US
Practice Address - Phone:847-543-1055
Practice Address - Fax:847-543-8648
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4915076OtherBCBS
IL4915076OtherBCBS