MEDICARE: KIM M. 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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care

General Provider Information

NPI Number	:	1649877168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM M. BOLTON

Provider Business Mailing Address
First Line	:	3666 W 159TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-5706
Country	:	US
Telephone Number	:	216-548-2980
Fax Number	:

Provider Business Practice Location Address
First Line	:	3666 W 159TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-5706
Country	:	US
Telephone Number	:	216-548-2980
Fax Number	:

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

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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Directions to “ KIM M. BOLTON ” Practice Location

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