Healthcare Provider Details

I. General information

NPI: 1558963066
Provider Name (Legal Business Name): TIMOTHY ALLEN BOLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7331 BELLE PLAIN DR
HUBER HEIGHTS OH
45424-3225
US

IV. Provider business mailing address

7331 BELLE PLAIN DR
HUBER HEIGHTS OH
45424-3225
US

V. Phone/Fax

Practice location:
  • Phone: 937-237-7581
  • Fax:
Mailing address:
  • Phone: 937-237-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: