MEDICARE: MR. PABLO ERNESTO BUSTAMANTE JR.

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	311ZA0620X	Adult Care Home Facility		TX
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1861606501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PABLO ERNESTO BUSTAMANTE JR.

Provider Business Mailing Address
First Line	:	2029 ANISE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-2619
Country	:	US
Telephone Number	:	915-591-2017
Fax Number	:

Provider Business Practice Location Address
First Line	:	2029 ANISE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-2619
Country	:	US
Telephone Number	:	915-591-2017
Fax Number	:

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	05/14/2019

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