Healthcare Provider Details

I. General information

NPI: 1407489081
Provider Name (Legal Business Name): KATHERINE BOLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 EAST MARKET STREET
PINE BLUFF AR
71601
US

IV. Provider business mailing address

2911 EAST MARKET STREET
PINE BLUFF AR
71601
US

V. Phone/Fax

Practice location:
  • Phone: 870-850-6400
  • Fax:
Mailing address:
  • Phone: 870-850-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: