1255355780 NPI number — MRS. NICOLE SUZANNE BOLDA I PT

Table of content: MRS. NICOLE SUZANNE BOLDA I PT (NPI 1255355780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255355780 NPI number — MRS. NICOLE SUZANNE BOLDA I PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDA
Provider First Name:
NICOLE
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
I
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIRN
Provider Other First Name:
NICOLE
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255355780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-3251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
329 W 84TH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-6245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-791-9021
Provider Business Practice Location Address Fax Number:
219-791-9022
Provider Enumeration Date:
07/27/2006

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: 225100000X , with the licence number:  05004492A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 070008573 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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