Healthcare Provider Details

I. General information

NPI: 1326114232
Provider Name (Legal Business Name): VANESSA T BENAVIDEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 NORWICH AVE
PUEBLO CO
81003-1058
US

IV. Provider business mailing address

PO BOX 76510
COLORADO SPRINGS CO
80970-6510
US

V. Phone/Fax

Practice location:
  • Phone: 719-671-4342
  • Fax: 719-543-4787
Mailing address:
  • Phone: 719-638-8844
  • Fax: 719-638-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number87802
License Number StateCO

VIII. Authorized Official

Name: VANESSA T BENAVIDEZ
Title or Position: OWNER
Credential: CST, FA
Phone: 719-671-4342