Provider Demographics
NPI:1558936716
Name:BASTARDO, KIMBERLY (HIS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BASTARDO
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 PILLSBURY RD STE 194
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1373
Mailing Address - Country:US
Mailing Address - Phone:530-343-2350
Mailing Address - Fax:530-343-2505
Practice Address - Street 1:2201 PILLSBURY RD STE 194
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1373
Practice Address - Country:US
Practice Address - Phone:530-343-2350
Practice Address - Fax:530-343-2505
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA8696237700000X
CAHA8656237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013239037Medicaid