Healthcare Provider Details

I. General information

NPI: 1942075825
Provider Name (Legal Business Name): ERNESTO BANUELOS RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12019 SW STEAMBOAT DR
BEAVERTON OR
97008-7046
US

IV. Provider business mailing address

12019 SW STEAMBOAT DR
BEAVERTON OR
97008-7046
US

V. Phone/Fax

Practice location:
  • Phone: 909-827-0670
  • Fax:
Mailing address:
  • Phone: 909-827-0670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10235654
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: