Provider Demographics
NPI:1740507607
Name:BOLIVAR FAMILY MEDICAL CLINIC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:BOLIVAR FAMILY MEDICAL CLINIC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALVARO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-888-5552
Mailing Address - Street 1:598 N F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3110
Mailing Address - Country:US
Mailing Address - Phone:909-888-5552
Mailing Address - Fax:909-884-7530
Practice Address - Street 1:598 N F ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3110
Practice Address - Country:US
Practice Address - Phone:909-888-5552
Practice Address - Fax:909-884-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty