Provider Demographics
NPI:1891320248
Name:BUENO, EDGAR GABRIEL
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:GABRIEL
Last Name:BUENO
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 1:1414 S MILLER ST STE 11
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6916
Mailing Address - Country:US
Mailing Address - Phone:805-739-1512
Mailing Address - Fax:805-739-2855
Practice Address - Street 1:1414 S MILLER ST STE 11
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6916
Practice Address - Country:US
Practice Address - Phone:805-739-1512
Practice Address - Fax:805-739-2855
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA261QRO405XMedicaid