Provider Demographics
NPI:1720769367
Name:MAZIBUKO, BONGANI PETER
Entity Type:Individual
Prefix:MR
First Name:BONGANI
Middle Name:PETER
Last Name:MAZIBUKO
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 1:16616 MILLWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-8221
Mailing Address - Country:US
Mailing Address - Phone:913-742-3141
Mailing Address - Fax:
Practice Address - Street 1:9013 STATEN ISLAND DR
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9671
Practice Address - Country:US
Practice Address - Phone:661-501-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA157209325310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility