Provider Demographics
NPI:1669463105
Name:BOLL MEDICAL, INC
Entity Type:Organization
Organization Name:BOLL MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:M.
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WEEMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-345-2944
Mailing Address - Street 1:PO BOX 11810
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-1810
Mailing Address - Country:US
Mailing Address - Phone:304-345-2944
Mailing Address - Fax:304-345-2957
Practice Address - Street 1:1223 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1814
Practice Address - Country:US
Practice Address - Phone:304-345-2944
Practice Address - Fax:304-345-2957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV279779332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0147067000Medicaid
WV001705317OtherBLUE CROSS BLUE SHIELD PR
WV041242100OtherFEDERAL BLACK LUNG
WV041242100OtherFEDERAL BLACK LUNG