Basic Information
| Provider Information | |||||||||
| NPI: | 1407336167 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BOLLINGER | ||||||||
| FirstName: | IVORYNE | ||||||||
| MiddleName: | MAUDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 MIDWESTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763022210 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 910 MIDWESTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763022210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407675500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 204409 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.