Individual
MR. CARLOS BASTARDO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
11191 SHADYLANE DR, PLYMOUTH, IN 46563-8623
(574) 936-4152
(312) 256-9390
Mailing address
11191 SHADYLANE DR, PLYMOUTH, IN 46563-8623
(574) 936-4152
(312) 256-9390
Taxonomy
Speciality
Code
Description
License number
State
405300000X
Prevention Professional
Primary
3577690
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3577690
NATIONAL PRODUCER NUMBER
IN
Enumeration date
01/03/2017
Last updated
01/03/2017
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