Provider Demographics
NPI:1437876257
Name:BUSTAMANTE, BOSE (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:BOSE
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 THE ALAMEDA APT 2212
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3169
Mailing Address - Country:US
Mailing Address - Phone:951-880-8682
Mailing Address - Fax:
Practice Address - Street 1:2501 ALVIN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1660
Practice Address - Country:US
Practice Address - Phone:408-238-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23440225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist