Provider Demographics
NPI:1326690835
Name:BANUELOS, LUIS GUILLERMO SR
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GUILLERMO
Last Name:BANUELOS
Suffix:SR
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 1:44199 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3096
Mailing Address - Country:US
Mailing Address - Phone:760-770-2286
Mailing Address - Fax:
Practice Address - Street 1:44199 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3096
Practice Address - Country:US
Practice Address - Phone:760-770-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist