Healthcare Provider Details

I. General information

NPI: 1063664514
Provider Name (Legal Business Name): FAUSTINO BERNADETT JR MD INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 ELM AVE 100
LONG BEACH CA
90813-3264
US

IV. Provider business mailing address

PO BOX 2677
LOS ALAMITOS CA
90720-7677
US

V. Phone/Fax

Practice location:
  • Phone: 714-973-2650
  • Fax: 714-973-2655
Mailing address:
  • Phone: 714-973-2650
  • Fax: 714-973-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG44925
License Number StateCA

VIII. Authorized Official

Name: DR. FAUSTINO BERNADETT JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 714-973-2650