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General NPI Number Information
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NPI Number | 1013440718
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Entity Type | Organization
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Legal Business Name | BOLAND PROSTHETIC & ORTHOTIC CENTER LLC
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Dates
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Enumeration Date | 04/10/2017
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Last Update Date | 11/11/2021
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Provider Practice Location Address
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Address Line | 1673 WESLEYAN DR
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City | MACON
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State | GA
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Zip | 31210-1031
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Country | US
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Telephone | 478-996-5191
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Fax | 478-953-2927
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Provider Business Mailing Address
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Address Line | 1673 WESLEYAN DR
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City | MACON
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State | GA
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Zip | 31210-1031
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Country | US
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Telephone | 478-996-5191
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Fax | 478-953-2927
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Authorized Official
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Title or Position | OWNER
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Name | MR. PAUL A BOLAND
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Credential | CPO
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Telephone | 478-953-2922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 300760100
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License Number State | GA
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