Basic Information
| Provider Information | |||||||||
| NPI: | 1861576803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | CESAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 406153 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5616888877 | ||||||||
| Practice Location | |||||||||
| Address1: | 10701 SW 38TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331653618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052255471 | ||||||||
| FaxNumber: | 3052255481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | AS3784 | FL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 610250600 | 05 | FL | MEDICAID |