Provider Demographics
NPI:1053764977
Name:BOULDEN, MARK EDWARD JR (ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:BOULDEN
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6418
Mailing Address - Country:US
Mailing Address - Phone:843-527-1800
Mailing Address - Fax:843-527-6528
Practice Address - Street 1:2185 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6418
Practice Address - Country:US
Practice Address - Phone:843-527-1800
Practice Address - Fax:843-527-6528
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer