Provider Demographics
NPI:1053962498
Name:BOLDEN, CHERRY (CEO)
Entity type:Individual
Prefix:
First Name:CHERRY
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3752
Mailing Address - Country:US
Mailing Address - Phone:785-979-8660
Mailing Address - Fax:
Practice Address - Street 1:1126 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-4530
Practice Address - Country:US
Practice Address - Phone:785-424-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB023022261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care