MEDICARE: KEVIN MICHAEL BOLTON

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	2255A2300X	Athletic Trainer	RTO000220	PA

General Provider Information

NPI Number	:	1093578577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MICHAEL BOLTON

Provider Business Mailing Address
First Line	:	2601 CRESTLINE CT
Second Line	:
City	:	GLEN MILLS
State	:	PA
Zip	:	19342-8132
Country	:	US
Telephone Number	:	610-937-0688
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 CRESTLINE CT
Second Line	:
City	:	GLEN MILLS
State	:	PA
Zip	:	19342-8132
Country	:	US
Telephone Number	:	610-937-0688
Fax Number	:

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

Provider Enumeration Date	:	02/06/2024
Last Update Date	:	02/06/2024

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