1114918364 NPI number — BOLSTER & JEFFRIES HEALTH CARE GROUP LLC

Table of content: (NPI 1114918364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114918364 NPI number — BOLSTER & JEFFRIES HEALTH CARE GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLSTER & JEFFRIES HEALTH CARE GROUP LLC
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:
6
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:
1114918364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42220-0427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-265-5321
Provider Business Mailing Address Fax Number:
270-265-3126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 ALLENSVILLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42220-8834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-265-5321
Provider Business Practice Location Address Fax Number:
270-265-3126
Provider Enumeration Date:
11/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOLSTER
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
270-265-5321

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100395 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12504288 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90005877 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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