Basic Information
Provider Information
NPI: 1376011692
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEON-BUSTILLOS
FirstName: PHILICIA
MiddleName: ANASTACIA
NamePrefix:  
NameSuffix:  
Credential: RBT-17-29221
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 90 MARGUERITE DR
Address2:  
City: HOLLISTER
State: CA
PostalCode: 950239082
CountryCode: US
TelephoneNumber: 8318019039
FaxNumber:  
Practice Location
Address1: 4 ROSSI CIR STE 141
Address2:  
City: SALINAS
State: CA
PostalCode: 939072358
CountryCode: US
TelephoneNumber: 8314245565
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/05/2018
LastUpdateDate: 11/05/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XRBT-17-29221CAY    

No ID Information.


Home