Provider Demographics
NPI:1225335573
Name:BOLZ, BRIAN JOHN (LPN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOHN
Last Name:BOLZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LORRAINE BLVD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-5711
Mailing Address - Country:US
Mailing Address - Phone:845-462-3015
Mailing Address - Fax:
Practice Address - Street 1:13 LORRAINE BLVD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-5711
Practice Address - Country:US
Practice Address - Phone:845-462-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296643-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse