MEDICARE: BOLANOS-MCMAHAN, LLC.

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	171M00000X	Case Manager/Care Coordinator
2	174400000X	Specialist

General Provider Information

NPI Number	:	1922246610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLANOS-MCMAHAN, LLC.

Provider Business Mailing Address
First Line	:	401 E LAS OLAS BLVD STE 130-451
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2210
Country	:	US
Telephone Number	:	561-891-9148
Fax Number	:	954-607-5852

Provider Business Practice Location Address
First Line	:	401 E LAS OLAS BLVD STE 130-451
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2210
Country	:	US
Telephone Number	:	561-891-9148
Fax Number	:	954-607-5852

Authorized Official
Title or Position	:	MGRM
Name	:	JENNIFER LYNN MCMAHAN
Credential	:	OTR/L
Telephone Number	:	561-891-9148

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	07/16/2009

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