1689082711 NPI number — SAMUEL A. BOLIVAR, MD INC

Table of content: (NPI 1689082711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689082711 NPI number — SAMUEL A. BOLIVAR, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL A. BOLIVAR, MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689082711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3410 LA SIERRA AVE
Provider Second Line Business Mailing Address:
F369
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92503-5270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-888-8154
Provider Business Mailing Address Fax Number:
909-888-9940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 N D ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92401-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-888-8154
Provider Business Practice Location Address Fax Number:
909-888-9940
Provider Enumeration Date:
08/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BOLIVAR
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
909-888-8154

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  A41590 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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