Healthcare Provider Details

I. General information

NPI: 1891201653
Provider Name (Legal Business Name): ROXANNE BAUTISTA LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 POMONA BLVD
LOS ANGELES CA
90022-1716
US

IV. Provider business mailing address

5425 POMONA BLVD
LOS ANGELES CA
90022-1716
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-0411
  • Fax: 323-832-7677
Mailing address:
  • Phone: 323-728-0411
  • Fax: 323-832-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: