Healthcare Provider Details

I. General information

NPI: 1487074167
Provider Name (Legal Business Name): BANUELOS FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 W MICHIGAN AVE STE 10C
PENSACOLA FL
32505-2346
US

IV. Provider business mailing address

945 W MICHIGAN AVE STE 10C
PENSACOLA FL
32505-2346
US

V. Phone/Fax

Practice location:
  • Phone: 850-490-6727
  • Fax:
Mailing address:
  • Phone: 850-490-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME97139
License Number StateFL

VIII. Authorized Official

Name: DR. ELIAS I BANUELOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-490-6727