Provider Demographics
NPI:1417372475
Name:BOLD SELAH, LLC
Entity Type:Organization
Organization Name:BOLD SELAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:845-797-4177
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-0001
Mailing Address - Country:US
Mailing Address - Phone:845-797-4177
Mailing Address - Fax:
Practice Address - Street 1:394 LATTINTOWN RD
Practice Address - Street 2:BASEMENT
Practice Address - City:MARLBORO
Practice Address - State:NY
Practice Address - Zip Code:12542-5507
Practice Address - Country:US
Practice Address - Phone:845-797-4177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY374J00000XMedicaid