Provider Demographics
NPI:1871942888
Name:BOLTON, BARRY WARRIS
Entity type:Individual
Prefix:MR
First Name:BARRY
Middle Name:WARRIS
Last Name:BOLTON
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 1:712B LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427
Mailing Address - Country:US
Mailing Address - Phone:985-750-4511
Mailing Address - Fax:985-732-1095
Practice Address - Street 1:712B LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427
Practice Address - Country:US
Practice Address - Phone:985-750-4511
Practice Address - Fax:985-732-1095
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03679828172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA03679828OtherDRIVER LICENSE