Healthcare Provider Details

I. General information

NPI: 1003599242
Provider Name (Legal Business Name): ALEXIS VILLANUEVA BUENAVENTURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 S PROSPECT AVE STE A
TUSTIN CA
92780-1523
US

IV. Provider business mailing address

2700 PETERSON PL APT 48C
COSTA MESA CA
92626-5370
US

V. Phone/Fax

Practice location:
  • Phone: 415-646-6223
  • Fax:
Mailing address:
  • Phone: 213-400-3002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberY7143218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: