Provider Demographics
NPI:1154199057
Name:BAZAR, ALTHEA MAE BONTILAO (PT)
Entity type:Individual
Prefix:
First Name:ALTHEA MAE
Middle Name:BONTILAO
Last Name:BAZAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 S SPALDING DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4103
Mailing Address - Country:US
Mailing Address - Phone:213-374-6836
Mailing Address - Fax:
Practice Address - Street 1:38121 25TH ST E APT I202
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4977
Practice Address - Country:US
Practice Address - Phone:213-374-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist