Provider Demographics
NPI:1013440718
Name:BOLAND PROSTHETIC & ORTHOTIC CENTER LLC
Entity type:Organization
Organization Name:BOLAND PROSTHETIC & ORTHOTIC CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:478-953-2922
Mailing Address - Street 1:1673 WESLEYAN DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1031
Mailing Address - Country:US
Mailing Address - Phone:478-996-5191
Mailing Address - Fax:478-953-2927
Practice Address - Street 1:1673 WESLEYAN DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1031
Practice Address - Country:US
Practice Address - Phone:478-996-5191
Practice Address - Fax:478-953-2927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA300760100335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier