Provider Demographics
NPI:1568058493
Name:BOLTE, REBECCA ORA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ORA
Last Name:BOLTE
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 1:3825 LAKE VISTA RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44319-2668
Mailing Address - Country:US
Mailing Address - Phone:330-631-8625
Mailing Address - Fax:
Practice Address - Street 1:3977 MAYFAIR RD APT 103
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-8770
Practice Address - Country:US
Practice Address - Phone:430-699-9727
Practice Address - Fax:330-699-9727
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH773132692701Medicaid