Provider Demographics
NPI:1063020816
Name:BOLDEN, PRECIOUS LAQUON
Entity Type:Individual
Prefix:
First Name:PRECIOUS
Middle Name:LAQUON
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 N STATE HIGHWAY 360 APT 371
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-4108
Mailing Address - Country:US
Mailing Address - Phone:262-751-0253
Mailing Address - Fax:
Practice Address - Street 1:1450 N STATE HIGHWAY 360 APT 371
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-4108
Practice Address - Country:US
Practice Address - Phone:262-751-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45590009172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver