MEDICARE: LUKE RAYMOND BOLT MS, RDN, ACSM EP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian		WA

General Provider Information

NPI Number	:	1427904648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE RAYMOND BOLT MS, RDN, ACSM EP-C

Provider Business Mailing Address
First Line	:	12515 GRAVELLY LAKE DR SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-1423
Country	:	US
Telephone Number	:	253-495-8191
Fax Number	:

Provider Business Practice Location Address
First Line	:	12515 GRAVELLY LAKE DR SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-1423
Country	:	US
Telephone Number	:	253-495-8191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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