Provider Demographics
NPI:1619579950
Name:BOLEN, AMBER (PT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:SINGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:4730 VILLAGE PLAZA LOOP STE 145
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6679
Mailing Address - Country:US
Mailing Address - Phone:541-654-0802
Mailing Address - Fax:
Practice Address - Street 1:4730 VILLAGE PLAZA LOOP STE 145
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6679
Practice Address - Country:US
Practice Address - Phone:541-654-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist