Provider Demographics
NPI:1568617439
Name:BOLIVAR, ROSALBA (RD,LD LN)
Entity Type:Individual
Prefix:MRS
First Name:ROSALBA
Middle Name:
Last Name:BOLIVAR
Suffix:
Gender:F
Credentials:RD,LD LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 DUNDEE TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1405
Mailing Address - Country:US
Mailing Address - Phone:305-556-8562
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:ACC EAST 1ST FLOOR
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-5241
Practice Address - Fax:305-585-5065
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered