Basic Information
| Provider Information | |||||||||
| NPI: | 1770257297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIDALGO | ||||||||
| FirstName: | BONN DEMETRIO | ||||||||
| MiddleName: | MISO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15259 ADAMS DR | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917063404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269914385 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2021 | ||||||||
| LastUpdateDate: | 08/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.