Provider Demographics
NPI:1083650295
Name:BOLEN, CARLENE ADRIA (DC)
Entity Type:Individual
Prefix:DR
First Name:CARLENE
Middle Name:ADRIA
Last Name:BOLEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N ASPEN AVE STE 101B
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-251-8800
Mailing Address - Fax:918-251-8802
Practice Address - Street 1:409 N ASPEN AVE STE 101B
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-251-8800
Practice Address - Fax:918-251-8802
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3532111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK241414218Medicare ID - Type Unspecified
OKU85479Medicare UPIN