Provider Demographics
NPI:1457629180
Name:BANEZ, JAYZON BELENO (LVN)
Entity Type:Individual
Prefix:MR
First Name:JAYZON
Middle Name:BELENO
Last Name:BANEZ
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 MESA VERDE DR E APT H207
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4985
Mailing Address - Country:US
Mailing Address - Phone:714-270-1982
Mailing Address - Fax:
Practice Address - Street 1:2775 MESA VERDE DR E APT H207
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4985
Practice Address - Country:US
Practice Address - Phone:714-270-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212080164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0382Medicare UPIN