Healthcare Provider Details

I. General information

NPI: 1972246643
Provider Name (Legal Business Name): ROGER BENAVIDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

IV. Provider business mailing address

3695 HOT SPRINGS BLVD
LAS VEGAS NM
87701-9549
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-2100
  • Fax: 505-454-0397
Mailing address:
  • Phone: 505-454-2100
  • Fax: 505-454-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: