MEDICARE: GWENDOLYN 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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1659785129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN BOLDEN

Provider Business Mailing Address
First Line	:	7326 MYSTERY RDG
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-2727
Country	:	US
Telephone Number	:	210-862-8211
Fax Number	:

Provider Business Practice Location Address
First Line	:	4615 WALZEM ROAD
Second Line	:	207
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218
Country	:	US
Telephone Number	:	210-862-8211
Fax Number	:

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

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	06/12/2014

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Directions to “ GWENDOLYN BOLDEN ” Practice Location

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