Provider Demographics
NPI:1346399789
Name:TAIRU-CASWELL, BOLALE (PT)
Entity Type:Individual
Prefix:
First Name:BOLALE
Middle Name:
Last Name:TAIRU-CASWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 IBISCA TER
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-4321
Mailing Address - Country:US
Mailing Address - Phone:561-718-7641
Mailing Address - Fax:
Practice Address - Street 1:104 IBISCA TER
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-4321
Practice Address - Country:US
Practice Address - Phone:561-718-7641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist