MEDICARE: CHARIS 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1790279974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARIS BOLDEN

Provider Business Mailing Address
First Line	:	8250 N GRAND CANYON DR UNIT 1140
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-3738
Country	:	US
Telephone Number	:	702-717-4880
Fax Number	:

Provider Business Practice Location Address
First Line	:	2580 N RANCHO DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3361
Country	:	US
Telephone Number	:	702-982-3636
Fax Number	:	702-982-3737

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

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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Directions to “ CHARIS BOLDEN ” Practice Location

Language	Start Address	Practice Location

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