1912641739 NPI number — HERLI MIJARES BENITEZ-DANAO PT

Table of content: MONICA LYNN MARTIN MARIETTA (NPI 1174411888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912641739 NPI number — HERLI MIJARES BENITEZ-DANAO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENITEZ-DANAO
Provider First Name:
HERLI
Provider Middle Name:
MIJARES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912641739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19845 LAKE CHABOT RD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASTRO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94546-4055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-200-9959
Provider Business Mailing Address Fax Number:
888-251-2818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19845 LAKE CHABOT RD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTRO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94546-4055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-200-9959
Provider Business Practice Location Address Fax Number:
888-251-2818
Provider Enumeration Date:
04/27/2022

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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