Healthcare Provider Details

I. General information

NPI: 1124817119
Provider Name (Legal Business Name): THOMAS BOLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 WILSHIRE BLVD STE 3003055
LOS ANGELES CA
90010-1108
US

IV. Provider business mailing address

3055 WILSHIRE BLVD STE 300
LOS ANGELES CA
90010-1147
US

V. Phone/Fax

Practice location:
  • Phone: 213-375-3830
  • Fax: 360-925-9882
Mailing address:
  • Phone: 213-375-3830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number137215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: