Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 0631512 | IL |
NPI | 1396019469 |
---|---|
Provider Name | Beverly Woltman |
First Address | Bolingbrook, IL 60440-1047 |
Second Address | Downers Grove, IL 60516 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2012 |
Last Update Date | 01/09/2020 |