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General NPI Number Information
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NPI Number | 1417492281
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Entity Type | Individual
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Provider Name | MR. CARLOS BASTARDO
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Gender | Male
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Dates
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Enumeration Date | 01/03/2017
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Last Update Date | 01/03/2017
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Provider Practice Location Address
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Address Line | 11191 SHADYLANE DR
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City | PLYMOUTH
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State | IN
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Zip | 46563-8623
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Country | US
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Telephone | 574-936-4152
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Fax | 312-256-9390
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Provider Business Mailing Address
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Address Line | 11191 SHADYLANE DR
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City | PLYMOUTH
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State | IN
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Zip | 46563-8623
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Country | US
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Telephone | 574-936-4152
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Fax | 312-256-9390
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | 3577690
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License Number State | IN
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