Provider Demographics
NPI:1508639642
Name:BOLAR, KEIONYA
Entity Type:Individual
Prefix:
First Name:KEIONYA
Middle Name:
Last Name:BOLAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250A W 86TH ST # 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3605
Mailing Address - Country:US
Mailing Address - Phone:833-576-9633
Mailing Address - Fax:
Practice Address - Street 1:3250A W 86TH ST # 1026
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3605
Practice Address - Country:US
Practice Address - Phone:833-576-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INBYMOJYL6U7224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist