Provider Demographics
NPI:1801041892
Name:BOLTON, KIMBERLY (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CRIM AVE
Mailing Address - Street 2:
Mailing Address - City:BELINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26250-9495
Mailing Address - Country:US
Mailing Address - Phone:304-823-3056
Mailing Address - Fax:
Practice Address - Street 1:1405 CRIM AVE
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-9495
Practice Address - Country:US
Practice Address - Phone:304-823-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2002-0950172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker