Healthcare Provider Details

I. General information

NPI: 1922011097
Provider Name (Legal Business Name): MARY D BOLT AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N CLIPPERT ST STE 4
LANSING MI
48912-4694
US

IV. Provider business mailing address

3945 OKEMOS RD STE B1
OKEMOS MI
48864-4207
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-1691
  • Fax: 517-324-0210
Mailing address:
  • Phone: 517-349-0200
  • Fax: 517-349-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: