Provider Demographics
NPI:1073201182
Name:BOLTON, TYMON NAKIA
Entity Type:Individual
Prefix:
First Name:TYMON
Middle Name:NAKIA
Last Name:BOLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5326 W MCNEIL ST
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-9606
Mailing Address - Country:US
Mailing Address - Phone:480-577-2858
Mailing Address - Fax:
Practice Address - Street 1:1949 E CARVER DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-2454
Practice Address - Country:US
Practice Address - Phone:480-577-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care