=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932756574
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP BOLAN PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2019
-----------------------------------------------------
Last Update Date | 08/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 VALLEY RD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44460-9725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-537-4621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46367 MILL ST
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44455-8712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-708-0594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PTA012385
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------