1649539347 NPI number — YONG SUN BOLTON MASSAGE THERAPIST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649539347 NPI number — YONG SUN BOLTON MASSAGE THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLTON
Provider First Name:
YONG
Provider Middle Name:
SUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASSAGE THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RO
Provider Other First Name:
YONG
Provider Other Middle Name:
SUN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASSAGE THERAPIST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649539347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11620 BROOK HILL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99516-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-202-3589
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4050 LAKE OTIS PKWY STE 201B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-5223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-202-3589
Provider Business Practice Location Address Fax Number:
907-334-1015
Provider Enumeration Date:
05/15/2012

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: 225700000X , with the licence number:  MAT:12513 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: 101896 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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