Provider Demographics
NPI:1598388530
Name:BAUTISTA HURTADO, TERESA (CLS/MLT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BAUTISTA HURTADO
Suffix:
Gender:F
Credentials:CLS/MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33527 4TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-2412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 PENOBSCOT DR
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-4737
Practice Address - Country:US
Practice Address - Phone:855-698-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTA-02044844291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTA-02044844OtherCALIFORNIA DEPARTMENT OF PUBLIC HEALTH
CA25707877OtherASCP