Provider Demographics
NPI:1841790367
Name:BOLES LLC
Entity Type:Organization
Organization Name:BOLES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:DOVEL
Authorized Official - Last Name:BOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:226-265-1323
Mailing Address - Street 1:2194 HARMANSON VUE
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-5273
Mailing Address - Country:US
Mailing Address - Phone:226-236-3872
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST STE 900
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:225-822-6965
Practice Address - Fax:226-822-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty