MEDICARE: TIMOTHY ALLEN BOLEN

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	376J00000X	Homemaker
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1558963066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY ALLEN BOLEN

Provider Business Mailing Address
First Line	:	7331 BELLE PLAIN DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3225
Country	:	US
Telephone Number	:	937-237-7581
Fax Number	:

Provider Business Practice Location Address
First Line	:	7331 BELLE PLAIN DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3225
Country	:	US
Telephone Number	:	937-237-7581
Fax Number	:

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

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	11/19/2020

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Directions to “ TIMOTHY ALLEN BOLEN ” Practice Location

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