Healthcare Provider Details

I. General information

NPI: 1295300051
Provider Name (Legal Business Name): LENNY BOLTON RADT I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5671 CHURCHWARD ST
SAN DIEGO CA
92114-4010
US

IV. Provider business mailing address

4526 ILLINOIS ST APT 10C
SAN DIEGO CA
92116-4375
US

V. Phone/Fax

Practice location:
  • Phone: 619-915-6452
  • Fax:
Mailing address:
  • Phone: 217-778-6786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: