Provider Demographics
NPI:1043277155
Name:BOLDT, RANDALL E (PT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:E
Last Name:BOLDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:1008 W 35TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5827
Practice Address - Country:US
Practice Address - Phone:563-324-2263
Practice Address - Fax:563-324-0719
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02562225100000X
IL070-008667225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA02562OtherIOWA PT LICENSE NUMBER
IL070-008667OtherILLINOIS PT LICENSE NO.
IL070-008667OtherILLINOIS PT LICENSE NO.
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