MEDICARE: MR. JUAN BAUTISTA

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1275840597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN BAUTISTA

Provider Business Mailing Address
First Line	:	7314 MIRAMONTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90001-2540
Country	:	US
Telephone Number	:	323-589-9043
Fax Number	:

Provider Business Practice Location Address
First Line	:	3605 LONG BEACH BLVD STE 331
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-4025
Country	:	US
Telephone Number	:	562-989-0537
Fax Number	:

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

Provider Enumeration Date	:	09/08/2010
Last Update Date	:	09/08/2010

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Directions to “ MR. JUAN BAUTISTA ” Practice Location

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