1578605010 NPI number — MR. MATTHEW BENJAMIN BUSTILLOS P.T.

Table of content: MR. MATTHEW BENJAMIN BUSTILLOS P.T. (NPI 1578605010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578605010 NPI number — MR. MATTHEW BENJAMIN BUSTILLOS P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTILLOS
Provider First Name:
MATTHEW
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578605010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27222 NOGAL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSION VIEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92692-3422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-367-1598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24731 ALICIA PKWY
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-4653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-588-7278
Provider Business Practice Location Address Fax Number:
949-588-7331
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT15153 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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