Provider Demographics
NPI:1467083865
Name:BODAJLA, ROBERT M
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:BODAJLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LANDINGS DR STE 308
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7649
Mailing Address - Country:US
Mailing Address - Phone:617-462-3175
Mailing Address - Fax:
Practice Address - Street 1:130 LANDINGS DR STE 308
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7649
Practice Address - Country:US
Practice Address - Phone:617-462-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer