Provider Demographics
NPI:1215991534
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:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVARO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-888-8152
Mailing Address - Street 1:10327 HOLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1747
Mailing Address - Country:US
Mailing Address - Phone:951-351-1600
Mailing Address - Fax:951-351-9400
Practice Address - Street 1:10327 HOLE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1747
Practice Address - Country:US
Practice Address - Phone:951-351-1600
Practice Address - Fax:951-351-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A532860Medicaid
CAZZZ19987ZMedicare PIN
CAA88452Medicare UPIN
CA00A532860Medicaid