Provider Demographics
NPI:1750851101
Name:BOLUM, CYRIL
Entity Type:Individual
Prefix:
First Name:CYRIL
Middle Name:
Last Name:BOLUM
Suffix:
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 1:3001 N MIDLAND DR APT J4
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5584
Mailing Address - Country:US
Mailing Address - Phone:432-599-0155
Mailing Address - Fax:
Practice Address - Street 1:3001 N MIDLAND DR APT J4
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-5584
Practice Address - Country:US
Practice Address - Phone:432-599-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor