Healthcare Provider Details

I. General information

NPI: 1295879435
Provider Name (Legal Business Name): MR. EDGAR ALAIN BASTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 W ROMNEYA DR STE D
ANAHEIM CA
92801-1805
US

IV. Provider business mailing address

256 SAN JOAQUIN ST
LAGUNA BEACH CA
92651-1351
US

V. Phone/Fax

Practice location:
  • Phone: 714-776-6692
  • Fax:
Mailing address:
  • Phone: 714-776-6692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberD6662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: