Provider Demographics
NPI:1174594519
Name:BOLTZ, MITCHELL S (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:S
Last Name:BOLTZ
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 1:2999 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-4216
Mailing Address - Country:US
Mailing Address - Phone:775-827-5995
Mailing Address - Fax:775-827-3216
Practice Address - Street 1:2999 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-4216
Practice Address - Country:US
Practice Address - Phone:775-827-5995
Practice Address - Fax:775-827-3216
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVB01169OtherPHYSICIAN LICENSE
IL038-008997OtherPHYSICIAN LICENSE
IL595700Medicare ID - Type UnspecifiedCOOK COUNTY - INACTIVE
IL705760Medicare ID - Type UnspecifiedDUPAGE COUNTY
ILU82071Medicare UPIN