Healthcare Provider Details

I. General information

NPI: 1447999651
Provider Name (Legal Business Name): CHRISTIAN BANTASAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 CENTER DR. 6TH FLOOR SUITE # 639
LOS ANGELES CA
90045
US

IV. Provider business mailing address

PO BOX 1295
VENICE CA
90294-1295
US

V. Phone/Fax

Practice location:
  • Phone: 888-859-0145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number48983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: