Provider Demographics
NPI:1184961351
Name:BUNCH, FREDDIE (LPT)
Entity type:Individual
Prefix:
First Name:FREDDIE
Middle Name:
Last Name:BUNCH
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6502
Mailing Address - Country:US
Mailing Address - Phone:619-239-4663
Mailing Address - Fax:619-239-3045
Practice Address - Street 1:734 10TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6502
Practice Address - Country:US
Practice Address - Phone:619-239-4663
Practice Address - Fax:619-239-3045
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26495167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician