Provider Demographics
NPI:1629797279
Name:BOLIVAR, JHON WILSON
Entity Type:Individual
Prefix:
First Name:JHON
Middle Name:WILSON
Last Name:BOLIVAR
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 1:160 MORRISON RD
Mailing Address - Street 2:
Mailing Address - City:EAST TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02718-1334
Mailing Address - Country:US
Mailing Address - Phone:904-444-4407
Mailing Address - Fax:
Practice Address - Street 1:160 MORRISON RD
Practice Address - Street 2:
Practice Address - City:EAST TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02718-1334
Practice Address - Country:US
Practice Address - Phone:904-444-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator