Healthcare Provider Details

I. General information

NPI: 1649623851
Provider Name (Legal Business Name): PATRICK BUENVIAJE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 E PALMDALE BLVD #128
PALMDALE CA
93550-4930
US

IV. Provider business mailing address

2009 SLAYTON ST
PALMDALE CA
93551-5408
US

V. Phone/Fax

Practice location:
  • Phone: 661-947-3333
  • Fax:
Mailing address:
  • Phone: 661-317-5234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number278140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: