MEDICARE: BOLT CHIROPRACTIC FAMILY WELLNESS, P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1700344454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLT CHIROPRACTIC FAMILY WELLNESS, P.C

Provider Business Mailing Address
First Line	:	15520 ROCKFIELD BLVD STE A200
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92618-6705
Country	:	US
Telephone Number	:	949-598-9999
Fax Number	:	949-598-9990

Provider Business Practice Location Address
First Line	:	433 W CHANNEL ISLANDS BLVD
Second Line	:
City	:	PORT HUENEME
State	:	CA
Zip	:	93041-2102
Country	:	US
Telephone Number	:	805-985-6867
Fax Number	:	805-985-6692

Authorized Official
Title or Position	:	OWNER
Name	:	DONALD BEN BOLT
Credential	:	D.C
Telephone Number	:	805-985-6867

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	07/22/2020

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