1013440718 NPI number — BOLAND PROSTHETIC & ORTHOTIC CENTER LLC

Table of content: MRS. RENEE WATSON ADAMS LPCA (NPI 1104248491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013440718 NPI number — BOLAND PROSTHETIC & ORTHOTIC CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLAND PROSTHETIC & ORTHOTIC CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013440718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1673 WESLEYAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-1031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-996-5191
Provider Business Mailing Address Fax Number:
478-953-2927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1673 WESLEYAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-1031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-996-5191
Provider Business Practice Location Address Fax Number:
478-953-2927
Provider Enumeration Date:
04/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BOLAND
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-953-2922

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  300760100 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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