Provider Demographics
NPI:1457620171
Name:BOLANDER, RICHARD ERIC (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ERIC
Last Name:BOLANDER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11987 SW KNIGHTSBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2729
Mailing Address - Country:US
Mailing Address - Phone:651-230-1771
Mailing Address - Fax:
Practice Address - Street 1:501 NW CASHMERE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1908
Practice Address - Country:US
Practice Address - Phone:772-204-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 14359171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor