Provider Demographics
NPI:1821587684
Name:BENAVIDES, JOSEPH MICA
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICA
Last Name:BENAVIDES
Suffix:
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 1:6425 COLUMBINE RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92344-0753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6425 COLUMBINE RD.
Practice Address - Street 2:
Practice Address - City:OAK HILLS
Practice Address - State:CA
Practice Address - Zip Code:92344
Practice Address - Country:US
Practice Address - Phone:760-686-7837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116671164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse