Provider Demographics
NPI:1922839133
Name:CASAVANTES SIAS, BERENICE CONCEPCION
Entity type:Individual
Prefix:
First Name:BERENICE
Middle Name:CONCEPCION
Last Name:CASAVANTES SIAS
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 1:874 ADA ST # 1
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2636
Mailing Address - Country:US
Mailing Address - Phone:619-735-0864
Mailing Address - Fax:
Practice Address - Street 1:1001 S HALE AVE SPC 54
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-2177
Practice Address - Country:US
Practice Address - Phone:858-729-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY9698802OtherCALIFORNIA IDENTIFICATION CARD