Provider Demographics
NPI:1750394466
Name:BOLES, REBECCA RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:RUSSELL
Last Name:BOLES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:RUSSELL
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1564 C.C. RD.
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139
Mailing Address - Country:US
Mailing Address - Phone:843-307-8782
Mailing Address - Fax:888-970-1470
Practice Address - Street 1:155 WEST MILLS STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722
Practice Address - Country:US
Practice Address - Phone:843-307-8782
Practice Address - Fax:888-970-1470
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3166111N00000X
NC4392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH3166Medicaid
SCAA15398576Medicare PIN
SCCH3166Medicaid
SC8576Medicare PIN
SCAA15390281Medicare PIN