Healthcare Provider Details

I. General information

NPI: 1053962498
Provider Name (Legal Business Name): CHERRY BOLDEN C.E.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 HILLTOP DR
LAWRENCE KS
66044-4530
US

IV. Provider business mailing address

1008 WILDWOOD DR
LAWRENCE KS
66049-3752
US

V. Phone/Fax

Practice location:
  • Phone: 785-424-7470
  • Fax:
Mailing address:
  • Phone: 785-979-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberB023022
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: