Provider Demographics
NPI:1952403206
Name:BOSCO, DINO G (DC)
Entity Type:Individual
Prefix:DR
First Name:DINO
Middle Name:G
Last Name:BOSCO
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 1:127 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2801
Mailing Address - Country:US
Mailing Address - Phone:847-680-3138
Mailing Address - Fax:847-680-5889
Practice Address - Street 1:127 E PARK AVENUE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2801
Practice Address - Country:US
Practice Address - Phone:847-680-3138
Practice Address - Fax:847-680-5889
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04920778OtherBLUE CROSS BLUE SHIELD
IL9925913001Medicare UPIN
IL04920778OtherBLUE CROSS BLUE SHIELD