Healthcare Provider Details

I. General information

NPI: 1073942934
Provider Name (Legal Business Name): MONICA BANUELOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 21ST ST
CLOVIS NM
88101-4151
US

IV. Provider business mailing address

1100 W 21ST ST
CLOVIS NM
88101-4151
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax: 575-769-8974
Mailing address:
  • Phone: 575-769-2345
  • Fax: 575-769-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberT-0161201
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: