Provider Demographics
NPI:1104191899
Name:BOLEN, TIMOTHY J (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:BOLEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:BOLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2311 S KANSAS RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-9032
Mailing Address - Country:US
Mailing Address - Phone:316-283-7187
Mailing Address - Fax:316-283-7189
Practice Address - Street 1:2311 S KANSAS RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9032
Practice Address - Country:US
Practice Address - Phone:316-283-7187
Practice Address - Fax:316-283-7189
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist