Provider Demographics
NPI:1770200925
Name:BOLES, ROGER
Entity type:Individual
Prefix:
First Name:ROGER
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 1:412 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1230
Mailing Address - Country:US
Mailing Address - Phone:937-402-8335
Mailing Address - Fax:
Practice Address - Street 1:412 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1230
Practice Address - Country:US
Practice Address - Phone:937-402-8335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker