Healthcare Provider Details

I. General information

NPI: 1912812918
Provider Name (Legal Business Name): DELEO A BLANKS BENITEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST STE 110
BOISE ID
83705-1961
US

IV. Provider business mailing address

1111 S ORCHARD ST STE 110
BOISE ID
83705-1961
US

V. Phone/Fax

Practice location:
  • Phone: 208-919-4692
  • Fax:
Mailing address:
  • Phone: 208-919-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAD019616D
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: