Healthcare Provider Details

I. General information

NPI: 1689184194
Provider Name (Legal Business Name): MARCOS VALDEBENITO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E BEACH ST
WATSONVILLE CA
95076-4809
US

IV. Provider business mailing address

247 SIERRA VISTA CT
APTOS CA
95003-4017
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-0222
  • Fax:
Mailing address:
  • Phone: 831-227-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95039789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: