Provider Demographics
NPI:1831267400
Name:BOLIN, GARY R (CO)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:BOLIN
Suffix:
Gender:M
Credentials:CO
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Mailing Address - Street 1:74 FAIRFIELD
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-1855
Mailing Address - Country:US
Mailing Address - Phone:949-716-9091
Mailing Address - Fax:949-916-9245
Practice Address - Street 1:74 FAIRFIELD
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-1855
Practice Address - Country:US
Practice Address - Phone:949-716-9091
Practice Address - Fax:949-916-9245
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO3161222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4469040001Medicare NSC