1750394466 NPI number — DR. REBECCA RUSSELL BOLES D.C.

Table of content: DR. REBECCA RUSSELL BOLES D.C. (NPI 1750394466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750394466 NPI number — DR. REBECCA RUSSELL BOLES D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLES
Provider First Name:
REBECCA
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
REBECCA
Provider Other Middle Name:
RUSSELL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750394466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1564 C.C. RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTHERFORDTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-307-8782
Provider Business Mailing Address Fax Number:
888-970-1470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 WEST MILLS STREET
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-307-8782
Provider Business Practice Location Address Fax Number:
888-970-1470
Provider Enumeration Date:
08/14/2006

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: 111N00000X , with the licence number:  3166 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 4392 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CH3166 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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