MEDICARE: EDWARD J BUSTAMANTE R.R.W.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1629365655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD J BUSTAMANTE R.R.W.

Provider Business Mailing Address
First Line	:	1227 FOSTER STREET
Second Line	:
City	:	BEAUMONT
State	:	CA
Zip	:	92223
Country	:	US
Telephone Number	:	909-380-4514
Fax Number	:

Provider Business Practice Location Address
First Line	:	68100 RAMON RD
Second Line	:
City	:	CATHEDRAL CTY
State	:	CA
Zip	:	92234-3387
Country	:	US
Telephone Number	:	760-321-0870
Fax Number	:

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

Provider Enumeration Date	:	06/28/2011
Last Update Date	:	06/30/2011

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