Healthcare Provider Details

I. General information

NPI: 1053853689
Provider Name (Legal Business Name): CONSUELA BOLANOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HARBOR BLVD
BELMONT CA
94002-4018
US

IV. Provider business mailing address

300 HARBOR BLVD
BELMONT CA
94002-4018
US

V. Phone/Fax

Practice location:
  • Phone: 650-817-9070
  • Fax: 650-817-9074
Mailing address:
  • Phone: 650-817-9070
  • Fax: 650-817-9074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN222079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: