Healthcare Provider Details

I. General information

NPI: 1093822389
Provider Name (Legal Business Name): KATHLEEN JOAN BOLAND OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 NATURAL BRIDGE RD PATIENT CARE CENTER
SAINT LOUIS MO
63121-4617
US

IV. Provider business mailing address

ONE UNIVERSITY BLVD PATIENT CARE CENTER
ST. LOUIS MO
63121
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5131
  • Fax: 314-516-5507
Mailing address:
  • Phone: 314-516-5131
  • Fax: 314-516-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2002020286
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2002020286
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: