Healthcare Provider Details

I. General information

NPI: 1851429971
Provider Name (Legal Business Name): BOLTON CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 AIRPORT RD N SUITE 204
FLOWOOD MS
39232-8827
US

IV. Provider business mailing address

115 W MADISON ST
BOLTON MS
39041
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-3191
  • Fax: 601-936-7193
Mailing address:
  • Phone: 601-866-7723
  • Fax: 601-866-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR652075
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIAM F KROOSS II
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 601-932-3191