Provider Demographics
NPI:1861224453
Name:BOLING, MARK (LACUP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BOLING
Suffix:
Gender:M
Credentials:LACUP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21986 CAYUGA LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2303
Mailing Address - Country:US
Mailing Address - Phone:949-588-9222
Mailing Address - Fax:
Practice Address - Street 1:21986 CAYUGA LN
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2303
Practice Address - Country:US
Practice Address - Phone:949-588-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist