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General NPI Number Information
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NPI Number | 1841790367
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Entity Type | Organization
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Legal Business Name | BOLES LLC
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Dates
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Enumeration Date | 02/21/2018
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Last Update Date | 12/11/2023
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Provider Practice Location Address
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Address Line | 4500 13TH ST STE 900
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City | GULFPORT
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State | MS
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Zip | 39501-2515
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Country | US
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Telephone | 225-822-6965
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Fax | 226-822-6999
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Provider Business Mailing Address
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Address Line | 2194 HARMANSON VUE
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City | BILOXI
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State | MS
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Zip | 39531-5273
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Country | US
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Telephone | 226-236-3872
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. NATHAN DOVEL BOLES
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Credential | MD
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Telephone | 226-265-1323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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