Provider Demographics
NPI:1740879527
Name:BOLANOS, VICENTE A I
Entity type:Individual
Prefix:
First Name:VICENTE
Middle Name:A
Last Name:BOLANOS
Suffix:I
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 1:4791 SW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3705
Mailing Address - Country:US
Mailing Address - Phone:786-515-7162
Mailing Address - Fax:
Practice Address - Street 1:501 NW 103RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3924
Practice Address - Country:US
Practice Address - Phone:954-251-1497
Practice Address - Fax:954-404-9537
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA74686225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist