Provider Demographics
NPI:1972029130
Name:BOLGOV, LILIA (MS, RD)
Entity Type:Individual
Prefix:
First Name:LILIA
Middle Name:
Last Name:BOLGOV
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 E 2ND ST APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3528 E 2ND ST
Practice Address - Street 2:APT 1
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803
Practice Address - Country:US
Practice Address - Phone:909-568-6382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1021166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered