Provider Demographics
NPI:1205618493
Name:BOLDS, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4217 OLD RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1459
Mailing Address - Country:US
Mailing Address - Phone:937-538-2427
Mailing Address - Fax:
Practice Address - Street 1:282 JAMES BOHANAN DR
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-2353
Practice Address - Country:US
Practice Address - Phone:937-538-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.022629225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist