Provider Demographics
NPI:1225671621
Name:BOLDEN AFC LLC
Entity Type:Organization
Organization Name:BOLDEN AFC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DORTHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-214-2142
Mailing Address - Street 1:71871 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9132
Mailing Address - Country:US
Mailing Address - Phone:268-214-2142
Mailing Address - Fax:
Practice Address - Street 1:7027 BASELINE RD
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8338
Practice Address - Country:US
Practice Address - Phone:269-214-2142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLDEN AFC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235789553Medicaid