Provider Demographics
NPI:1285100081
Name:BOLLER, PETER FRANKLIN GENE (PT)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:FRANKLIN GENE
Last Name:BOLLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23592 WINDSONG APT 50I
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1395
Mailing Address - Country:US
Mailing Address - Phone:805-210-0229
Mailing Address - Fax:
Practice Address - Street 1:23592 WINDSONG APT 50I
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-1395
Practice Address - Country:US
Practice Address - Phone:805-210-0229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist