Provider Demographics
NPI:1164419743
Name:BOLAND PROSTHETIC & ORTHOTIC CENTER
Entity Type:Organization
Organization Name:BOLAND PROSTHETIC & ORTHOTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, ORTHOTIST/PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:478-953-2922
Mailing Address - Street 1:110 OSIGIAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-953-2922
Mailing Address - Fax:478-953-2927
Practice Address - Street 1:110 OSIGIAN BLVD.
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-953-2922
Practice Address - Fax:478-953-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GANO STATE LICENSURE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00820751BMedicaid
GA00820751AMedicaid
GA00820751BMedicaid