Provider Demographics
NPI:1629365655
Name:BUSTAMANTE, EDWARD J (RRW)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 FOSTER STREET
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223
Mailing Address - Country:US
Mailing Address - Phone:909-380-4514
Mailing Address - Fax:
Practice Address - Street 1:68100 RAMON RD
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CTY
Practice Address - State:CA
Practice Address - Zip Code:92234-3387
Practice Address - Country:US
Practice Address - Phone:760-321-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)