Provider Demographics
NPI:1639303316
Name:BOLANOS, HIPOLITO TAEZA (PT)
Entity Type:Individual
Prefix:
First Name:HIPOLITO
Middle Name:TAEZA
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FIELDSTONE DR
Mailing Address - Street 2:18B
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1573
Mailing Address - Country:US
Mailing Address - Phone:917-767-4133
Mailing Address - Fax:
Practice Address - Street 1:30 FIELDSTONE DR
Practice Address - Street 2:18B
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1573
Practice Address - Country:US
Practice Address - Phone:917-767-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist