Healthcare Provider Details

I. General information

NPI: 1629688478
Provider Name (Legal Business Name): BRIANNA BOLTON RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3067 E COPPER POINT DR
MERIDIAN ID
83642-1740
US

IV. Provider business mailing address

7103 W BRENTWOOD DR
BOISE ID
83709-1925
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-1733
  • Fax: 208-287-1734
Mailing address:
  • Phone: 208-320-7995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRT-P-10207994
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRT-1708
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: