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NPI Code Detail

MEDICARE: MR. BONN DEMETRIO MISO HIDALGO III

MEDICARE: MR. BONN DEMETRIO MISO HIDALGO III
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
11041C0700XClinical Social Worker
2104100000XSocial Worker137368CA
3101YM0800XMental Health Counselor
4171M00000XCase Manager/Care Coordinator
5104100000XSocial Worker109311CA

General Provider Information

NPI Number : 1770257297
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BONN DEMETRIO MISO HIDALGO III
Provider Business Mailing Address
First Line : 15259 ADAMS DR
Second Line :
City : BALDWIN PARK
State : CA
Zip : 91706-3404
Country : US
Telephone Number : 626-991-4385
Fax Number :
Provider Business Practice Location Address
First Line : 4760 SEPULVEDA BLVD
Second Line :
City : CULVER CITY
State : CA
Zip : 90230-4820
Country : US
Telephone Number : 310-390-6612
Fax Number : 310-398-5690
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/07/2021
Last Update Date : 03/04/2026

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