Healthcare Provider Details

I. General information

NPI: 1871763169
Provider Name (Legal Business Name): RAUL BUENROSTRO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53220 BEALES ST
LAKE ELSINORE CA
92532-1608
US

IV. Provider business mailing address

53220 BEALES ST
LAKE ELSINORE CA
92532-1608
US

V. Phone/Fax

Practice location:
  • Phone: 323-445-0345
  • Fax:
Mailing address:
  • Phone: 323-445-0345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: