Healthcare Provider Details

I. General information

NPI: 1265640866
Provider Name (Legal Business Name): CAROLINE A BAUTISTA PHM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 N FAIR OAKS AVE
PASADENA CA
91103-1620
US

IV. Provider business mailing address

2738 HARMONY PL
LA CRESCENTA CA
91214-2111
US

V. Phone/Fax

Practice location:
  • Phone: 626-744-6005
  • Fax:
Mailing address:
  • Phone: 626-744-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0900X
TaxonomyMicrobiology Specialist/Technologist
License NumberPHM35613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: