MEDICARE: ELIJAH RAUL NIETO BFA

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	106S00000X	Behavior Technician	RBT-24-353576	IL

General Provider Information

NPI Number	:	1316781859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH RAUL NIETO BFA

Provider Business Mailing Address
First Line	:	255 38TH AVE STE F-I
Second Line	:
City	:	SAINT CHARLES
State	:	IL
Zip	:	60174-5411
Country	:	US
Telephone Number	:	630-509-8700
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 38TH AVE STE F-I
Second Line	:
City	:	SAINT CHARLES
State	:	IL
Zip	:	60174-5411
Country	:	US
Telephone Number	:	630-509-8700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2024
Last Update Date	:	06/20/2024

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