Provider Demographics
NPI:1134996499
Name:BOLES, ROBIN (LAC)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:BOLES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 BERKLEY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7128
Mailing Address - Country:US
Mailing Address - Phone:254-931-3569
Mailing Address - Fax:
Practice Address - Street 1:401 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-2667
Practice Address - Country:US
Practice Address - Phone:254-939-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02154171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC02154OtherTEXAS STATE MEDICAL BOARD OF EXAMINERS