1730956905 NPI number — MR. GONZALO BENAVIDES ESTRADA JR. PT

Table of content: MR. GONZALO BENAVIDES ESTRADA JR. PT (NPI 1730956905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730956905 NPI number — MR. GONZALO BENAVIDES ESTRADA JR. PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESTRADA
Provider First Name:
GONZALO
Provider Middle Name:
BENAVIDES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ESTRADA
Provider Other First Name:
JUN
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1730956905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HAZEL HAWKINS REHAB. SERVICES
Provider Second Line Business Mailing Address:
961A SUNSET DRIVE
Provider Business Mailing Address City Name:
HOLLISTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-635-1157
Provider Business Mailing Address Fax Number:
831-636-9547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HAZEL HAWKINS REHAB. SERVICES
Provider Second Line Business Practice Location Address:
961A SUNSET DRIVE
Provider Business Practice Location Address City Name:
HOLLISTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-635-1135
Provider Business Practice Location Address Fax Number:
831-636-9547
Provider Enumeration Date:
12/07/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT17835 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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