Provider Demographics
NPI:1932555612
Name:VALENZUELA, BALENTI
Entity Type:Individual
Prefix:
First Name:BALENTI
Middle Name:
Last Name:VALENZUELA
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 1:5932 ST BRONCO DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-9597
Mailing Address - Country:US
Mailing Address - Phone:575-390-4319
Mailing Address - Fax:
Practice Address - Street 1:5932 S BRONCO DR
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9597
Practice Address - Country:US
Practice Address - Phone:575-390-4319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM378759171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor