Provider Demographics
NPI:1023132073
Name:BOLZ, SHIHAN MARY (L AC)
Entity type:Individual
Prefix:MS
First Name:SHIHAN
Middle Name:MARY
Last Name:BOLZ
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BOLZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:L AC
Mailing Address - Street 1:310 E MONTE VISTA AVE STE B
Mailing Address - Street 2:SUITE B
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2813
Mailing Address - Country:US
Mailing Address - Phone:707-455-0637
Mailing Address - Fax:707-446-2053
Practice Address - Street 1:310 E MONTE VISTA AVE STE B
Practice Address - Street 2:SUITE B
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-2813
Practice Address - Country:US
Practice Address - Phone:707-455-0637
Practice Address - Fax:707-446-2053
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8695171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist