Provider Demographics
NPI:1134812175
Name:BANUELOS, MARIO
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:BANUELOS
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 1:3201 NORTHWEST AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1363
Mailing Address - Country:US
Mailing Address - Phone:360-602-1733
Mailing Address - Fax:
Practice Address - Street 1:3201 NORTHWEST AVE STE 6
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1363
Practice Address - Country:US
Practice Address - Phone:360-602-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171R00000XOther Service ProvidersInterpreter
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No332H00000XSuppliersEyewear Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No374U00000XNursing Service Related ProvidersHome Health Aide
No374J00000XNursing Service Related ProvidersDoula
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral