MEDICARE: MRS. LAURA STULTZ BOLINSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 22588	FL
2	225100000X	Physical Therapist	PT 008172	GA

General Provider Information

NPI Number	:	1063625457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA STULTZ BOLINSKI

Provider Business Mailing Address
First Line	:	195 E TALL OAKS CIR
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4450
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 SAN MARCO BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8536
Country	:	US
Telephone Number	:	904-398-4133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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