Individual
MR. JACQUE ARLIN BOUTWELL JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CFA
Contact information
Practice address
3301 COUNTY RD 6 E, ELKHART, IN 46514-7673
(574) 214-7504
(574) 262-3214
Mailing address
5146 RELIABLE PKWY, CHICAGO, IL 60686-0001
(574) 214-7504
(574) 262-3214
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
Primary
—
—
246ZS0410X
Surgical Technologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000577411
ANTHEM BCBS
IN
Enumeration date
01/24/2007
Last updated
11/25/2014
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