Provider Demographics
NPI:1124397534
Name:BUSTOS, OMAR NICHOLAS (MA)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:NICHOLAS
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:MA
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 1241
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92593-1241
Mailing Address - Country:US
Mailing Address - Phone:951-265-6644
Mailing Address - Fax:951-265-6644
Practice Address - Street 1:24275 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-7285
Practice Address - Country:US
Practice Address - Phone:951-677-5599
Practice Address - Fax:951-698-0461
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist