MEDICARE: MR. LESLIE ROY BOLTON IDC

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	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	INDEPENDENT DUTY COR	OTHER	VA	MILITARY

General Provider Information

NPI Number	:	1316146731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LESLIE ROY BOLTON IDC

Provider Business Mailing Address
First Line	:	1636 REGULUS AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-2200
Country	:	US
Telephone Number	:	757-492-2026
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 REGULUS AVE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-2200
Country	:	US
Telephone Number	:	757-492-2026
Fax Number	:

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

Provider Enumeration Date	:	07/16/2007
Last Update Date	:	07/16/2007

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