Provider Demographics
NPI:1417265208
Name:ROY BOLTON
Entity Type:Organization
Organization Name:ROY BOLTON
Other - Org Name:DOGWOOD MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-723-2355
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:903-723-2355
Mailing Address - Fax:903-723-1580
Practice Address - Street 1:704 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-2608
Practice Address - Country:US
Practice Address - Phone:903-723-2355
Practice Address - Fax:903-723-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0085013332B00000X, 332BC3200X, 332BN1400X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197874401Medicaid
TX181024403Medicaid
TX6093520002Medicare NSC
TX6449320001Medicare NSC