Provider Demographics
NPI:1508605577
Name:BOLTON, MYRACLE
Entity type:Individual
Prefix:
First Name:MYRACLE
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRACLE
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4113 REDONDA LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1423
Mailing Address - Country:US
Mailing Address - Phone:937-580-7861
Mailing Address - Fax:
Practice Address - Street 1:465 W GRAND AVE APT 905
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4787
Practice Address - Country:US
Practice Address - Phone:937-744-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant