1386627818 NPI number — BOLTON HEALTHCARE, LLC

Table of content: (NPI 1386627818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386627818 NPI number — BOLTON HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLTON HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GUARDIAN ANGEL HOME HEALTH CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386627818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 841
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75839-0841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-764-0033
Provider Business Mailing Address Fax Number:
903-764-1556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 S FRAZIER ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77301-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-828-3739
Provider Business Practice Location Address Fax Number:
936-828-3741
Provider Enumeration Date:
11/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOLTON
Authorized Official First Name:
ROY
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-764-0033

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  012073 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251J00000X , with the licence number: 1810244-03 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1810244 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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