MEDICARE: LENNY BOLTON RADT I

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	172V00000X	Community Health Worker	CA
2	373H00000X	Day Training/Habilitation Specialist	CA
3	390200000X	Student in an Organized Health Care Education/Training Program
4	225400000X	Rehabilitation Practitioner	CA

General Provider Information

NPI Number	:	1295300051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENNY BOLTON RADT I

Provider Business Mailing Address
First Line	:	4526 ILLINOIS ST APT 10C
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4375
Country	:	US
Telephone Number	:	217-778-6786
Fax Number	:

Provider Business Practice Location Address
First Line	:	5671 CHURCHWARD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-4010
Country	:	US
Telephone Number	:	619-915-6452
Fax Number	:

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

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	05/08/2026

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