Healthcare Provider Details

I. General information

NPI: 1750152344
Provider Name (Legal Business Name): BENJAMIN MORALES MANACOP III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 E COOLEY DR STE 103
COLTON CA
92324-3901
US

IV. Provider business mailing address

1007 E COOLEY DR STE 103
COLTON CA
92324-3901
US

V. Phone/Fax

Practice location:
  • Phone: 951-727-6460
  • Fax:
Mailing address:
  • Phone: 909-219-5336
  • Fax: 909-219-5336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95030284
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number631790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: