Provider Demographics
NPI:1730807355
Name:BUSTOS, SUNNY JAMES BAUTISTA
Entity type:Individual
Prefix:
First Name:SUNNY JAMES
Middle Name:BAUTISTA
Last Name:BUSTOS
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 1:13049 MISTY MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4535
Mailing Address - Country:US
Mailing Address - Phone:951-452-6691
Mailing Address - Fax:
Practice Address - Street 1:13049 MISTY MEADOW CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4535
Practice Address - Country:US
Practice Address - Phone:951-452-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28941314000000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility