Provider Demographics
NPI:1629346135
Name:BOBO, HAROLD L JR
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:L
Last Name:BOBO
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 1:1956 S BASS LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9557
Mailing Address - Country:US
Mailing Address - Phone:989-539-5427
Mailing Address - Fax:
Practice Address - Street 1:1956 S BASS LAKE AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9557
Practice Address - Country:US
Practice Address - Phone:989-539-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF180073186171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor