Healthcare Provider Details

I. General information

NPI: 1124773221
Provider Name (Legal Business Name): BOLDJAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2138 S INDIANA AVE APT 805
CHICAGO IL
60616-5151
US

IV. Provider business mailing address

2138 S INDIANA AVE APT 805
CHICAGO IL
60616-5151
US

V. Phone/Fax

Practice location:
  • Phone: 832-713-3354
  • Fax:
Mailing address:
  • Phone: 832-713-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name: JULIUS AMAEFULE
Title or Position: CFO
Credential:
Phone: 832-713-3354