Healthcare Provider Details

I. General information

NPI: 1255854998
Provider Name (Legal Business Name): KELLI BOLTON MA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 MONTGOMERY ST
CUSTER SD
57730-1124
US

IV. Provider business mailing address

639 NORTHERN LIGHTS BLVD APT 3304
BOX ELDER SD
57719-6399
US

V. Phone/Fax

Practice location:
  • Phone: 605-840-4794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000017784
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: