1689268369 NPI number — BOLT ONS

Table of content: (NPI 1689268369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689268369 NPI number — BOLT ONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLT ONS
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:
NEXT STEP PROSTHETICS
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:
1689268369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 BIRCH AVE SUITE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-772-5777
Provider Business Mailing Address Fax Number:
928-271-8459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 W. BIRCH AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-772-5777
Provider Business Practice Location Address Fax Number:
928-271-8459
Provider Enumeration Date:
02/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KAYSER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICIAN/OWNER
Authorized Official Telephone Number:
928-255-8665

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 089633 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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