Provider Demographics
NPI:1750152344
Name:MANACOP, BENJAMIN MORALES III
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MORALES
Last Name:MANACOP
Suffix:III
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 1:1007 E COOLEY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3901
Mailing Address - Country:US
Mailing Address - Phone:951-727-6460
Mailing Address - Fax:
Practice Address - Street 1:1007 E COOLEY DR STE 103
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3901
Practice Address - Country:US
Practice Address - Phone:951-727-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631790163WX0200X
CA95030284363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WX0200XNursing Service ProvidersRegistered NurseOncology