Basic Information
| Provider Information | |||||||||
| NPI: | 1477054047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENAVIDES | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | REANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10225 MONTE VISTA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917633716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095757230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 845 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096241233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2018 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.