Provider Demographics
NPI:1639645211
Name:BOLES, JERRY LEE JR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:BOLES
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 1:1026 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2717
Mailing Address - Country:US
Mailing Address - Phone:541-941-4085
Mailing Address - Fax:
Practice Address - Street 1:1026 BEALL LN
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2717
Practice Address - Country:US
Practice Address - Phone:541-941-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)