Provider Demographics
NPI:1467568816
Name:BOLEN, GARY EUGENE (DC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:EUGENE
Last Name:BOLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 SOUTH TAMIAMI TRAIL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293
Mailing Address - Country:US
Mailing Address - Phone:941-497-7424
Mailing Address - Fax:941-493-8413
Practice Address - Street 1:4107 SOUTH TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293
Practice Address - Country:US
Practice Address - Phone:941-497-7424
Practice Address - Fax:941-493-8413
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7387111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U71893Medicare UPIN
55735Medicare ID - Type Unspecified