Healthcare Provider Details

I. General information

NPI: 1053541433
Provider Name (Legal Business Name): RAY BOLANDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 HOUSTON OAKS DR
PARIS KY
40361-2704
US

IV. Provider business mailing address

PO BOX 5
GARRISON KY
41141-0005
US

V. Phone/Fax

Practice location:
  • Phone: 606-584-1169
  • Fax: 800-584-1465
Mailing address:
  • Phone: 606-584-1169
  • Fax: 800-584-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberA01522
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: