Provider Demographics
NPI:1427548544
Name:BOLD CITY THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:BOLD CITY THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:904-551-0946
Mailing Address - Street 1:1605 KING STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204
Mailing Address - Country:US
Mailing Address - Phone:904-551-0946
Mailing Address - Fax:904-551-0974
Practice Address - Street 1:1605 KING STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-551-0946
Practice Address - Fax:904-551-0974
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-14
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23708261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy