Provider Demographics
NPI:1679867667
Name:ROLLY POLLIES LLC
Entity Type:Organization
Organization Name:ROLLY POLLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-507-9554
Mailing Address - Street 1:12700 SHOPS PKWY
Mailing Address - Street 2:SUITE 450
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-6597
Mailing Address - Country:US
Mailing Address - Phone:410-507-9554
Mailing Address - Fax:512-259-9595
Practice Address - Street 1:12700 SHOPS PKWY
Practice Address - Street 2:SUITE 450
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-6597
Practice Address - Country:US
Practice Address - Phone:410-507-9554
Practice Address - Fax:512-259-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX563100000261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center