Healthcare Provider Details

I. General information

NPI: 1962880195
Provider Name (Legal Business Name): FAUSAT BELLO CCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 BARCELONA DR
FREMONT CA
94536-2604
US

IV. Provider business mailing address

570 BARCELONA DR
FREMONT CA
94536-2604
US

V. Phone/Fax

Practice location:
  • Phone: 310-871-8587
  • Fax:
Mailing address:
  • Phone: 310-871-8587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberD7190192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: