Healthcare Provider Details

I. General information

NPI: 1013718436
Provider Name (Legal Business Name): MARITA BOLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

IV. Provider business mailing address

1186 LOSTINDA ST
EL CAJON CA
92019-3255
US

V. Phone/Fax

Practice location:
  • Phone: 714-463-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: