Healthcare Provider Details

I. General information

NPI: 1558936716
Provider Name (Legal Business Name): KIMBERLY BASTARDO HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 PILLSBURY RD STE 194
CHICO CA
95926-1373
US

IV. Provider business mailing address

2201 PILLSBURY RD STE 194
CHICO CA
95926-1373
US

V. Phone/Fax

Practice location:
  • Phone: 530-343-2350
  • Fax: 530-343-2505
Mailing address:
  • Phone: 530-343-2350
  • Fax: 530-343-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA8696
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA8656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: