MEDICARE: BOLD HEALTHCARE INNOVATIONS MANAGEMENT

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1073900049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLD HEALTHCARE INNOVATIONS MANAGEMENT

Provider Business Mailing Address
First Line	:	6505 MELWOOD ST APT 2323
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1791
Country	:	US
Telephone Number	:	214-250-0315
Fax Number	:

Provider Business Practice Location Address
First Line	:	6505 MELWOOD ST APT 2323
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1791
Country	:	US
Telephone Number	:	214-250-0315
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SEAN BOLDEN
Credential	:
Telephone Number	:	214-250-0315

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	05/13/2015

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