Provider Demographics
NPI:1073872537
Name:BENITEZ, MIGUEL ALFONSO (RN)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ALFONSO
Last Name:BENITEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2583 ROBERTS AVE.
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611
Mailing Address - Country:US
Mailing Address - Phone:559-312-7520
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-512-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53611163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse