Healthcare Provider Details

I. General information

NPI: 1326105495
Provider Name (Legal Business Name): BERT BOVARD BOLDT II BS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EAGLES WAY UNIT 333
CARRABELLE FL
32322-8020
US

IV. Provider business mailing address

1 EAGLES WAY UNIT 333
CARRABELLE FL
32322-8020
US

V. Phone/Fax

Practice location:
  • Phone: 850-519-4966
  • Fax: 850-597-9122
Mailing address:
  • Phone: 850-519-4966
  • Fax: 850-597-9122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0829
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: