Provider Demographics
NPI:1649866336
Name:BENAVIDEZ, ADINA JOSPEHINE
Entity type:Individual
Prefix:
First Name:ADINA
Middle Name:JOSPEHINE
Last Name:BENAVIDEZ
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 1:2300 W COUNTY ROAD 38 E LOT 268
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6466
Mailing Address - Country:US
Mailing Address - Phone:970-222-5326
Mailing Address - Fax:
Practice Address - Street 1:2300 W COUNTY ROAD 38 E LOT 268
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6466
Practice Address - Country:US
Practice Address - Phone:970-222-5326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO170610569172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty