Provider Demographics
NPI:1245749688
Name:BOLD HEALTH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BOLD HEALTH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:BOLD HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:PAPIER
Authorized Official - Last Name:HIRST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-503-4703
Mailing Address - Street 1:561 SAXONY PL STE 101
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:561 SAXONY PL STE 101
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7700
Practice Address - Country:US
Practice Address - Phone:760-503-5703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder