Provider Demographics
NPI:1548775117
Name:BOLEY, CLIFTON JR
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:BOLEY
Suffix:JR
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 1:1459 DEARING FORD RD
Mailing Address - Street 2:
Mailing Address - City:ALTAVISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24517-3033
Mailing Address - Country:US
Mailing Address - Phone:434-485-9750
Mailing Address - Fax:
Practice Address - Street 1:1459 DEARING FORD RD
Practice Address - Street 2:
Practice Address - City:ALTAVISTA
Practice Address - State:VA
Practice Address - Zip Code:24517-3033
Practice Address - Country:US
Practice Address - Phone:434-485-9750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver