MEDICARE: PRECIOUS LAQUON BOLDEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	45590009	TX

General Provider Information

NPI Number	:	1063020816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRECIOUS LAQUON BOLDEN

Provider Business Mailing Address
First Line	:	1450 N STATE HIGHWAY 360 APT 371
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-4108
Country	:	US
Telephone Number	:	262-751-0253
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 N STATE HIGHWAY 360 APT 371
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-4108
Country	:	US
Telephone Number	:	262-751-0253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2020
Last Update Date	:	07/17/2020

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Directions to “ PRECIOUS LAQUON BOLDEN ” Practice Location

Language	Start Address	Practice Location

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