=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881038628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY CARE IPA INLAND EMPIRE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2013
-----------------------------------------------------
Last Update Date | 01/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 590 N SIERRA WAY
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-495-3595
-----------------------------------------------------
Fax | 909-763-2544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 590 N SIERRA WAY
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-495-3595
-----------------------------------------------------
Fax | 909-763-2544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALVARO BOLIVAR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-888-8152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A38312
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------