1811178577 NPI number — BOLTON FAMILY MEDICAL CLINIC, P.C.

Table of content: (NPI 1811178577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811178577 NPI number — BOLTON FAMILY MEDICAL CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLTON FAMILY MEDICAL CLINIC, P.C.
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:
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:
1811178577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALTILLO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38866-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-869-0033
Provider Business Mailing Address Fax Number:
662-869-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2781 HIGHWAY 145
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALTILLO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38866-9783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-869-0033
Provider Business Practice Location Address Fax Number:
662-869-0053
Provider Enumeration Date:
11/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOLTON
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
662-869-0033

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16344 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09623207 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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