MEDICARE: MRS. AURORA BUSTILLOS RNC-MNN, IBCLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	578013	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BUS1-0429-7211	OTHER	TX	NCC
2	578013	OTHER	TX	BOARD OF NURSE EXAMINERS
3	10920319	OTHER	TX	IBLCE

General Provider Information

NPI Number	:	1891080404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AURORA BUSTILLOS RNC-MNN, IBCLC

Provider Business Mailing Address
First Line	:	1500 S MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4917
Country	:	US
Telephone Number	:	817-702-7524
Fax Number	:	817-920-6596

Provider Business Practice Location Address
First Line	:	1201 S MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4804
Country	:	US
Telephone Number	:	817-702-7524
Fax Number	:	817-920-6596

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

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	10/23/2014

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