Provider Demographics
NPI:1144784067
Name:BOLAR, KELVIN LAMONT
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:LAMONT
Last Name:BOLAR
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 1:1218 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4152
Mailing Address - Country:US
Mailing Address - Phone:904-269-2437
Mailing Address - Fax:
Practice Address - Street 1:1218 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4152
Practice Address - Country:US
Practice Address - Phone:904-269-2437
Practice Address - Fax:904-264-2330
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor