Healthcare Provider Details

I. General information

NPI: 1326604539
Provider Name (Legal Business Name): MARTHA DEL BOSQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR STE 300
SANTA ANA CA
92701-5017
US

IV. Provider business mailing address

1875 MONROVIA AVE APT B1
COSTA MESA CA
92627-4518
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 714-362-1335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: