Provider Demographics
NPI:1912316621
Name:LODGE, BO
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:LODGE
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 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1710 W 1ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-1840
Practice Address - Country:US
Practice Address - Phone:319-273-8988
Practice Address - Fax:319-273-8992
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist