Provider Demographics
NPI:1518682962
Name:BUSTILLO, HAZIEL
Entity Type:Individual
Prefix:
First Name:HAZIEL
Middle Name:
Last Name:BUSTILLO
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 1:529 W QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE STE P3
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4626
Practice Address - Country:US
Practice Address - Phone:949-694-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach