Provider Demographics
NPI:1477054047
Name:BENAVIDES, VANESSA REANN
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:REANN
Last Name:BENAVIDES
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 1:10225 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-3716
Mailing Address - Country:US
Mailing Address - Phone:909-575-7230
Mailing Address - Fax:
Practice Address - Street 1:845 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:909-624-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility