Provider Demographics
NPI:1992155204
Name:KENNETH D BOLTZ OD LLC
Entity type:Organization
Organization Name:KENNETH D BOLTZ OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOLTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-284-0794
Mailing Address - Street 1:5775 PERIMETER DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3238
Mailing Address - Country:US
Mailing Address - Phone:614-763-5775
Mailing Address - Fax:614-675-3338
Practice Address - Street 1:5775 PERIMETER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3238
Practice Address - Country:US
Practice Address - Phone:614-763-5775
Practice Address - Fax:614-675-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty