Provider Demographics
NPI:1114742632
Name:BAUTISTA, CRISTOBAL CRISTIAN (RD)
Entity type:Individual
Prefix:
First Name:CRISTOBAL
Middle Name:CRISTIAN
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5644
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92248-5644
Mailing Address - Country:US
Mailing Address - Phone:760-485-8408
Mailing Address - Fax:
Practice Address - Street 1:79125 CORPORATE CENTER DR
Practice Address - Street 2:#5644
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-9998
Practice Address - Country:US
Practice Address - Phone:760-485-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86059164133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered