Healthcare Provider Details

I. General information

NPI: 1104011345
Provider Name (Legal Business Name): KARLOMIKHAIL NONO BUENASEDA I PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 WHITTIER BLVD
PICO RIVERA CA
90660-2444
US

IV. Provider business mailing address

226 E 31ST ST
LONG BEACH CA
90807-5004
US

V. Phone/Fax

Practice location:
  • Phone: 562-801-4626
  • Fax: 562-801-4630
Mailing address:
  • Phone: 562-912-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 33472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: