Healthcare Provider Details

I. General information

NPI: 1629535604
Provider Name (Legal Business Name): DIEGO BAUTISTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 S BEVERLY DRIVE #214
BEVERELY HILLS CA
90212
US

IV. Provider business mailing address

4177 ISABELLA CIR
LAKE ELSINORE CA
92530-2032
US

V. Phone/Fax

Practice location:
  • Phone: 303-922-4636
  • Fax: 303-922-4640
Mailing address:
  • Phone: 714-322-9932
  • Fax: 303-922-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: