Provider Demographics
NPI:1386689560
Name:BOLTON, RICHARD E (IDC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:BOLTON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3524 NW PRINCETON LN
Mailing Address - Street 2:14-102
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-620-0276
Mailing Address - Fax:360-396-4247
Practice Address - Street 1:2100 THRESHER AVE
Practice Address - Street 2:USS NEVADA
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315
Practice Address - Country:US
Practice Address - Phone:360-315-4208
Practice Address - Fax:360-396-4247
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman