MEDICARE: GRANT BOLTJES PT

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	2251P0200X	Pediatric Physical Therapist	1072	SD

General Provider Information

NPI Number	:	1598111346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT BOLTJES PT

Provider Business Mailing Address
First Line	:	3513 S HARMONY DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-6032
Country	:	US
Telephone Number	:	605-371-0432
Fax Number	:

Provider Business Practice Location Address
First Line	:	3513 S HARMONY DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-6032
Country	:	US
Telephone Number	:	605-371-0432
Fax Number	:

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

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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