Provider Demographics
NPI:1154654663
Name:BOLDON, BRUCE E (LAC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:BOLDON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5041
Mailing Address - Country:US
Mailing Address - Phone:530-708-1628
Mailing Address - Fax:
Practice Address - Street 1:2021 SMITH FLAT RD
Practice Address - Street 2:SUITE A
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5038
Practice Address - Country:US
Practice Address - Phone:530-708-1628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3226171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist