Healthcare Provider Details

I. General information

NPI: 1518634914
Provider Name (Legal Business Name): MS. KARINA BANUELOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16650 SHERMAN WAY
VAN NUYS CA
91406-3782
US

IV. Provider business mailing address

1750 S LONGWOOD AVE APT 1
LOS ANGELES CA
90019-5516
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-4836
  • Fax:
Mailing address:
  • Phone: 323-320-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: