Healthcare Provider Details

I. General information

NPI: 1942777164
Provider Name (Legal Business Name): BETH BOLDERY REEG/EPT,CNIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 OLD CREEK DR
TYLER TX
75703-7642
US

IV. Provider business mailing address

1356 OLD CREEK DR
TYLER TX
75703-7642
US

V. Phone/Fax

Practice location:
  • Phone: 903-534-8812
  • Fax: 903-939-9149
Mailing address:
  • Phone: 903-534-8812
  • Fax: 903-939-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number3497
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: