Provider Demographics
NPI:1912579558
Name:ROBERTA L NIETO M.D. , P.C.
Entity Type:Organization
Organization Name:ROBERTA L NIETO M.D. , P.C.
Other - Org Name:BOUNTIFUL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-942-2643
Mailing Address - Street 1:2811 E KATELLA AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5247
Mailing Address - Country:US
Mailing Address - Phone:714-942-2643
Mailing Address - Fax:
Practice Address - Street 1:2811 E KATELLA AVE STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5247
Practice Address - Country:US
Practice Address - Phone:714-942-2643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-13
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty