Basic Information
| Provider Information | |||||||||
| NPI: | 1578605010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSTILLOS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27222 NOGAL | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926923422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493671598 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24731 ALICIA PKWY | ||||||||
| Address2: | UNIT B | ||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926534653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495887278 | ||||||||
| FaxNumber: | 9495887331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT15153 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.