1245850882 NPI number — ANDREW BOLT

Table of content: ANDREW BOLT (NPI 1245850882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245850882 NPI number — ANDREW BOLT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLT
Provider First Name:
ANDREW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1245850882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10019 LENOX ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34711-9114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-469-1823
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 W CRYSTAL LAKE ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-4476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-254-2500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2020

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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