MEDICARE: KEJUAN 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1114810215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEJUAN BOLDEN

Provider Business Mailing Address
First Line	:	7749 ISLEY AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-4008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 N NELLIS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-5507
Country	:	US
Telephone Number	:	619-343-8284
Fax Number	:

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

Provider Enumeration Date	:	05/29/2025
Last Update Date	:	05/29/2025

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Directions to “ KEJUAN BOLDEN ” Practice Location

Language	Start Address	Practice Location

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