1215127808 NPI number — BOLEN CHIROPRACTIC, PA

Table of content: (NPI 1215127808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215127808 NPI number — BOLEN CHIROPRACTIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLEN CHIROPRACTIC, PA
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:
Provider Other Organization Name Type Code:
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:
1215127808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2730 PIEDMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-6710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-728-3630
Provider Business Mailing Address Fax Number:
218-786-0399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 PIEDMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-728-3630
Provider Business Practice Location Address Fax Number:
218-786-0399
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOLEN
Authorized Official First Name:
TROY
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC/ PRESIDENT
Authorized Official Telephone Number:
218-728-3630

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3323 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 5673 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 350005070 . This is a "MEDICARE PART B" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1023379526 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38911400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5C086BO . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1023379526 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 838818100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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