Provider Demographics
NPI:1952903254
Name:BOLTON, ANTHONY (TRANSPORTATION)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:TRANSPORTATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 BURLINGAME AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49509-1246
Mailing Address - Country:US
Mailing Address - Phone:616-233-0615
Mailing Address - Fax:616-988-6425
Practice Address - Street 1:3322 LOUSMA DR SE STE 502
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2200
Practice Address - Country:US
Practice Address - Phone:616-233-0615
Practice Address - Fax:616-988-6425
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver