Provider Demographics
NPI:1861606501
Name:BUSTAMANTE, PABLO ERNESTO JR
Entity type:Individual
Prefix:MR
First Name:PABLO
Middle Name:ERNESTO
Last Name:BUSTAMANTE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LOVING
Other - Middle Name:AGE
Other - Last Name:AFC LTC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2029 ANISE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-2619
Mailing Address - Country:US
Mailing Address - Phone:915-591-2017
Mailing Address - Fax:
Practice Address - Street 1:2029 ANISE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-2619
Practice Address - Country:US
Practice Address - Phone:915-591-2017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311ZA0620X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home