Provider Demographics
NPI:1033167754
Name:BOLDEN, GARY (RKT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 5TH ST S
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 M ST SW
Practice Address - Street 2:THIRD FLOOR (3RD.) S.W.
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-3621
Practice Address - Country:US
Practice Address - Phone:817-361-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1469226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist