MEDICARE: MR. RICHARD S BALDONADO RVT

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	246XC2903X	Vascular Specialist/Technologist Cardiovascular	80940	CA

General Provider Information

NPI Number	:	1295079259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD S BALDONADO RVT

Provider Business Mailing Address
First Line	:	3534 SANTA CARLOTTA ST
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-1115
Country	:	US
Telephone Number	:	818-957-1652
Fax Number	:	818-957-4672

Provider Business Practice Location Address
First Line	:	3534 SANTA CARLOTTA ST
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-1115
Country	:	US
Telephone Number	:	818-957-1652
Fax Number	:	818-957-4672

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

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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