Healthcare Provider Details

I. General information

NPI: 1881342830
Provider Name (Legal Business Name): NICHOLAS JERARD BOLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MCCALEP-MCINTOSH HALL- BHWTP2, GRADUATE OF S W
NORMAL AL
35762
US

IV. Provider business mailing address

107 MCCALEP-MCINTOSH HALL- BHWTP2, GRADUATE OF S W
NORMAL AL
35762
US

V. Phone/Fax

Practice location:
  • Phone: 205-601-6657
  • Fax: 205-206-9777
Mailing address:
  • Phone: 205-601-6657
  • Fax: 205-206-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: