Provider Demographics
NPI:1760089304
Name:PERALTA, BUENAVENTURA (COTA/L)
Entity Type:Individual
Prefix:
First Name:BUENAVENTURA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 N WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-5643
Mailing Address - Country:US
Mailing Address - Phone:909-528-2355
Mailing Address - Fax:
Practice Address - Street 1:139 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-5643
Practice Address - Country:US
Practice Address - Phone:909-528-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant