Provider Demographics
NPI:1942408471
Name:BOLAK, KEVIN JOHN (CP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:BOLAK
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 HORTON RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1112
Mailing Address - Country:US
Mailing Address - Phone:231-215-1419
Mailing Address - Fax:231-744-7120
Practice Address - Street 1:3324 GLADE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2708
Practice Address - Country:US
Practice Address - Phone:231-215-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECP002002224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F10293OtherBCBSM PROVIDER PIN
MI0F10293OtherBCBSM PROVIDER PIN