MEDICARE: TREY BOLES

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	2255A2300X	Athletic Trainer
2	225100000X	Physical Therapist	PT37711	FL

General Provider Information

NPI Number	:	1932659604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREY BOLES

Provider Business Mailing Address
First Line	:	4575 US HIGHWAY 17 STE 350
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4825
Country	:	US
Telephone Number	:	502-525-4621
Fax Number	:

Provider Business Practice Location Address
First Line	:	4575 US HIGHWAY 17 STE 350
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4825
Country	:	US
Telephone Number	:	904-637-0148
Fax Number	:

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

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	07/31/2023

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Directions to “ TREY BOLES ” Practice Location

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