MEDICARE: MARVIN ICBAN BAUTISTA D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC28034	CA

General Provider Information

NPI Number	:	1215012778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN ICBAN BAUTISTA D.C.

Provider Business Mailing Address
First Line	:	130 YOLO CT
Second Line	:
City	:	SAN BRUNO
State	:	CA
Zip	:	94066-2555
Country	:	US
Telephone Number	:	650-892-3669
Fax Number	:	650-225-0510

Provider Business Practice Location Address
First Line	:	931 SAN BRUNO AVE W RM 7
Second Line	:
City	:	SAN BRUNO
State	:	CA
Zip	:	94066-3435
Country	:	US
Telephone Number	:	650-225-0500
Fax Number	:	650-225-0510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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