Healthcare Provider Details

I. General information

NPI: 1194909069
Provider Name (Legal Business Name): RICHARD C BOLEWARE CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OLD RIVER PL STE D
JACKSON MS
39202-3435
US

IV. Provider business mailing address

2 OLD RIVER PL STE D
JACKSON MS
39202-3435
US

V. Phone/Fax

Practice location:
  • Phone: 601-944-1130
  • Fax: 601-355-7476
Mailing address:
  • Phone: 601-944-1130
  • Fax: 601-355-7476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP003226
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: