Healthcare Provider Details

I. General information

NPI: 1033167754
Provider Name (Legal Business Name): GARY BOLDEN R.K.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 M ST SW THIRD FLOOR (3RD.) S.W.
WASHINGTON DC
20024-3621
US

IV. Provider business mailing address

2101 5TH ST S
ARLINGTON VA
22204-1932
US

V. Phone/Fax

Practice location:
  • Phone: 817-361-0602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1469
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: