Healthcare Provider Details

I. General information

NPI: 1144805854
Provider Name (Legal Business Name): DAVID RAYNE BUENO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 BURNS AVE
LOS ANGELES CA
90029-2702
US

IV. Provider business mailing address

4456 LOCKWOOD AVE APT 301
LOS ANGELES CA
90029-2731
US

V. Phone/Fax

Practice location:
  • Phone: 323-664-8969
  • Fax:
Mailing address:
  • Phone: 323-664-8969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: