Healthcare Provider Details

I. General information

NPI: 1851063556
Provider Name (Legal Business Name): BENJAMIN J. BOLDT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 01/19/2026
Certification Date: 01/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W LAS CRUCES AVE
LAS CRUCES NM
88005-1804
US

IV. Provider business mailing address

7012 RAASAF DR
LAS CRUCES NM
88005-4621
US

V. Phone/Fax

Practice location:
  • Phone: 575-249-0390
  • Fax:
Mailing address:
  • Phone: 575-649-9275
  • Fax: 575-267-6228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: