Provider Demographics
NPI:1477361780
Name:BOLES, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BOLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 CIRCLE DR APT 8
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-2432
Mailing Address - Country:US
Mailing Address - Phone:859-380-7102
Mailing Address - Fax:
Practice Address - Street 1:78 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NELSONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45764-1135
Practice Address - Country:US
Practice Address - Phone:513-470-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1187506175T00000X
OHAPS.005878175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist