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General NPI Number Information
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NPI Number | 1053441378
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Entity Type | Individual
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Provider Name | MARY CARLA BOLAN A.T.C., L.A.T.
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Gender | Female
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 474 OLD SAN ANTONIO HWY.
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City | BANDERA
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State | TX
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Zip | 78003
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Country | US
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Telephone | 830-796-5549
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Fax | 830-796-7934
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Provider Business Mailing Address
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Address Line | PO BOX 1924 693 WHISPERING WINDS RD.
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City | BANDERA
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State | TX
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Zip | 78003-1924
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Country | US
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Telephone | 830-796-6308
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Fax | 830-796-7934
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT1434
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License Number State | TX
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