Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FC0800X | Contact Lens |
NPI | 1215586482 |
---|---|
Provider Name | Ms. Raven Bolden |
First Address | Bingham Farms, MI 48025-2454 |
Second Address | Bingham Farms, MI 48025-2454 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2019 |
Last Update Date | 10/09/2019 |