Provider Demographics
NPI:1912370842
Name:BOLISAY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOLISAY
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 1:5740 RALSTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6051
Mailing Address - Country:US
Mailing Address - Phone:805-339-3739
Mailing Address - Fax:
Practice Address - Street 1:5740 RALSTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6051
Practice Address - Country:US
Practice Address - Phone:805-339-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278713164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse