Healthcare Provider Details

I. General information

NPI: 1255677902
Provider Name (Legal Business Name): MR. EDGAR BERMUDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W WALNUT ST STE 375
PASADENA CA
91124-4915
US

IV. Provider business mailing address

100 W WALNUT ST STE 375
PASADENA CA
91124-0001
US

V. Phone/Fax

Practice location:
  • Phone: 626-315-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: