Healthcare Provider Details

I. General information

NPI: 1932659604
Provider Name (Legal Business Name): TREY BOLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4575 US HIGHWAY 17 STE 350
FLEMING ISLAND FL
32003-4825
US

IV. Provider business mailing address

4575 US HIGHWAY 17 STE 350
FLEMING ISLAND FL
32003-4825
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0148
  • Fax:
Mailing address:
  • Phone: 502-525-4621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT37711
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: