Provider Demographics
NPI:1003599242
Name:BUENAVENTURA, ALEXIS VILLANUEVA
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:VILLANUEVA
Last Name:BUENAVENTURA
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 1:2700 PETERSON PL APT 48C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5370
Mailing Address - Country:US
Mailing Address - Phone:213-400-3002
Mailing Address - Fax:
Practice Address - Street 1:290 S PROSPECT AVE STE A
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1523
Practice Address - Country:US
Practice Address - Phone:415-646-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY71432182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer