Healthcare Provider Details

I. General information

NPI: 1790222958
Provider Name (Legal Business Name): MR. BENJAMIN FRANCO SUESCUN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S SUNWEST LN STE 108
SAN BERNARDINO CA
92408-3263
US

IV. Provider business mailing address

1950 S SUNWEST LN STE 108
SAN BERNARDINO CA
92408-3263
US

V. Phone/Fax

Practice location:
  • Phone: 909-521-8818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95063960
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: