Provider Demographics
NPI:1598111346
Name:BOLTJES, GRANT (PT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BOLTJES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 S HARMONY DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-6032
Mailing Address - Country:US
Mailing Address - Phone:605-371-0432
Mailing Address - Fax:
Practice Address - Street 1:3513 S HARMONY DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-6032
Practice Address - Country:US
Practice Address - Phone:605-371-0432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10722251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics