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General NPI Number Information
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NPI Number | 1740879527
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Entity Type | Individual
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Provider Name | VICENTE A BOLANOS I
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Gender | Male
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Dates
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Enumeration Date | 01/15/2021
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Last Update Date | 01/15/2021
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Provider Practice Location Address
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Address Line | 501 NW 103RD AVE
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-3924
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Country | US
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Telephone | 954-251-1497
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Fax | 954-404-9537
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Provider Business Mailing Address
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Address Line | 4791 SW 82ND AVE
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City | DAVIE
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State | FL
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Zip | 33328-3705
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Country | US
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Telephone | 786-515-7162
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Fax |
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA74686
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License Number State | FL
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