1952342008 NPI number — BETTY BOLTE LCP, LCAC

Table of content: BETTY BOLTE LCP, LCAC (NPI 1952342008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952342008 NPI number — BETTY BOLTE LCP, LCAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLTE
Provider First Name:
BETTY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCP, LCAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAY
Provider Other First Name:
BETTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952342008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66505-0747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-587-4300
Provider Business Mailing Address Fax Number:
785-587-4377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 CAROLINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUNCTION CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66441-5210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-762-5250
Provider Business Practice Location Address Fax Number:
785-762-2144
Provider Enumeration Date:
06/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  476 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 0517 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 904 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11658758 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 856659 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200440980A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".