Healthcare Provider Details

I. General information

NPI: 1508639642
Provider Name (Legal Business Name): KEIONYA BOLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250A W 86TH ST # 1026
INDIANAPOLIS IN
46268-3605
US

IV. Provider business mailing address

3250A W 86TH ST # 1026
INDIANAPOLIS IN
46268-3605
US

V. Phone/Fax

Practice location:
  • Phone: 833-576-9633
  • Fax:
Mailing address:
  • Phone: 833-576-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberBYMOJYL6U7
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: