Provider Demographics
NPI:1528626769
Name:BOSWICK, HALEY LORETTA (OD)
Entity type:Individual
Prefix:DR
First Name:HALEY
Middle Name:LORETTA
Last Name:BOSWICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 14TH ST APT 1403
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3672
Mailing Address - Country:US
Mailing Address - Phone:224-600-4846
Mailing Address - Fax:
Practice Address - Street 1:4214 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-1293
Practice Address - Country:US
Practice Address - Phone:708-453-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist