Healthcare Provider Details

I. General information

NPI: 1952903254
Provider Name (Legal Business Name): ANTHONY BOLTON TRANSPORTATION
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 LOUSMA DR SE STE 502
GRAND RAPIDS MI
49548-2200
US

IV. Provider business mailing address

1932 BURLINGAME AVE SW
GRAND RAPIDS MI
49509-1246
US

V. Phone/Fax

Practice location:
  • Phone: 616-233-0615
  • Fax: 616-988-6425
Mailing address:
  • Phone: 616-233-0615
  • Fax: 616-988-6425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: