=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609951722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOLEN CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 SCENIC HWY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-5729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-513-1591
-----------------------------------------------------
Fax | 770-513-0221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 SCENIC HWY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-5729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-513-1591
-----------------------------------------------------
Fax | 770-513-0221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT T. BOLEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 770-513-1591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 001396
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------