Basic Information
| Provider Information | |||||||||
| NPI: | 1487938411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLLING | ||||||||
| FirstName: | BRYANT | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 957 INDUSTRIAL RD STE B | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940704152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153757634 | ||||||||
| FaxNumber: | 6506209549 | ||||||||
| Practice Location | |||||||||
| Address1: | 957 INDUSTRIAL RD STE B | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940704152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153757634 | ||||||||
| FaxNumber: | 6506209549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2011 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.