Provider Demographics
NPI:1629126784
Name:BOLTON, JIMMY DEWAYNE SR (DC)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:DEWAYNE
Last Name:BOLTON
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5238 N US HIGHWAY 281
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-3844
Mailing Address - Country:US
Mailing Address - Phone:830-693-4055
Mailing Address - Fax:830-693-6277
Practice Address - Street 1:5238 US HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5708
Practice Address - Country:US
Practice Address - Phone:830-693-4055
Practice Address - Fax:830-693-6277
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT92494Medicare UPIN