Basic Information
Provider Information | |||||||||
NPI: | 1023062510 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLDER | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AU.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23838 VALENCIA BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913555319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612841900 | ||||||||
FaxNumber: | 6612841988 | ||||||||
Practice Location | |||||||||
Address1: | 23838 VALENCIA BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913555319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612841900 | ||||||||
FaxNumber: | 6612841988 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 04/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA3969 | CA | N |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   | 237600000X | AU1957 | CA | Y |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
ID Information
ID | Type | State | Issuer | Description | AU0019570 | 05 | CA |   | MEDICAID |