Provider Demographics
NPI:1386627818
Name:BOLTON HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BOLTON HEALTHCARE, LLC
Other - Org Name:GUARDIAN ANGEL HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-764-0033
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:TX
Mailing Address - Zip Code:75839-0841
Mailing Address - Country:US
Mailing Address - Phone:904-764-0033
Mailing Address - Fax:903-764-1556
Practice Address - Street 1:1300 S FRAZIER ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-4400
Practice Address - Country:US
Practice Address - Phone:936-828-3739
Practice Address - Fax:936-828-3741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012073251E00000X
TX1810244-03251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1810244Medicaid
TX1810244Medicaid
TX5433430001Medicare NSC