Provider Demographics
NPI:1750753703
Name:BOSE, JAMES (LMT, CPT, FST, PES)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BOSE
Suffix:
Gender:M
Credentials:LMT, CPT, FST, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 W 15TH ST
Mailing Address - Street 2:UNIT 414
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 W 15TH ST
Practice Address - Street 2:UNIT 414
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3154
Practice Address - Country:US
Practice Address - Phone:847-542-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.018139225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist