Provider Demographics
NPI:1679813653
Name:BUENROSTRO, MANUEL
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:BUENROSTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76002
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92809-7602
Mailing Address - Country:US
Mailing Address - Phone:951-372-0556
Mailing Address - Fax:
Practice Address - Street 1:1450 W 6TH ST STE 201
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-6516
Practice Address - Country:US
Practice Address - Phone:951-372-0556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN54651003416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport