Healthcare Provider Details

I. General information

NPI: 1174851257
Provider Name (Legal Business Name): RICHARD BOLTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE # 3
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 760-770-2241
  • Fax:
Mailing address:
  • Phone: 760-770-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: