Provider Demographics
NPI:1104022862
Name:BOLING, MYRON
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:BOLING
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 1:2902 SCOTCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8215
Mailing Address - Country:US
Mailing Address - Phone:870-273-2841
Mailing Address - Fax:
Practice Address - Street 1:210 MANOR ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1936
Practice Address - Country:US
Practice Address - Phone:870-739-6818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator