Provider Demographics
NPI:1215313630
Name:BOLT, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:BOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-234-9317
Mailing Address - Fax:
Practice Address - Street 1:212 RETREAT VLG STE 212
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2403
Practice Address - Country:US
Practice Address - Phone:912-638-1444
Practice Address - Fax:912-638-0077
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist