Provider Demographics
NPI:1053541433
Name:BOLANDER, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:BOLANDER
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:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:KY
Mailing Address - Zip Code:41141-0005
Mailing Address - Country:US
Mailing Address - Phone:606-584-1169
Mailing Address - Fax:800-584-1465
Practice Address - Street 1:436 HOUSTON OAKS DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-2704
Practice Address - Country:US
Practice Address - Phone:606-584-1169
Practice Address - Fax:800-584-1465
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01522171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor