Provider Demographics
NPI:1073365300
Name:BAUTISTA, HORACIO (CHW)
Entity Type:Individual
Prefix:
First Name:HORACIO
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13901 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2720
Mailing Address - Country:US
Mailing Address - Phone:313-821-2591
Mailing Address - Fax:313-822-0950
Practice Address - Street 1:111 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1968
Practice Address - Country:US
Practice Address - Phone:313-368-2600
Practice Address - Fax:313-369-2477
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI95396184172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker