Provider Demographics
NPI:1639794316
Name:REYES, SHIRLEY BUENSUCESO
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:BUENSUCESO
Last Name:REYES
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 1:11848 LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8270
Mailing Address - Country:US
Mailing Address - Phone:909-760-8200
Mailing Address - Fax:
Practice Address - Street 1:7124 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5916
Practice Address - Country:US
Practice Address - Phone:909-327-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA258276OtherLVN