Provider Demographics
NPI:1467881177
Name:BOLEY, JEFFERY LY
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:LY
Last Name:BOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 COLONIAL DR UNIT D
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2567
Mailing Address - Country:US
Mailing Address - Phone:318-450-7022
Mailing Address - Fax:318-450-3947
Practice Address - Street 1:45 COLONIAL DR UNIT D
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2567
Practice Address - Country:US
Practice Address - Phone:318-450-7022
Practice Address - Fax:318-450-3947
Is Sole Proprietor?:No
Enumeration Date:2013-11-03
Last Update Date:2013-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005026524172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver