Provider Demographics
NPI:1124574512
Name:BANUELOS, LAURA M
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24028 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325
Mailing Address - Country:US
Mailing Address - Phone:909-338-3222
Mailing Address - Fax:
Practice Address - Street 1:9500 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5871
Practice Address - Country:US
Practice Address - Phone:909-980-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator