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General NPI Number Information
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NPI Number | 1336567254
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Entity Type | Organization
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Legal Business Name | BANUELOS MEDICAL CLINIC PLLC
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Dates
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Enumeration Date | 03/29/2014
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Last Update Date | 09/05/2014
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Provider Practice Location Address
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Address Line | 945 W MICHIGAN AVE STE 10C
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City | PENSACOLA
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State | FL
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Zip | 32505-2346
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Country | US
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Telephone | 850-912-6179
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Fax | 888-404-5528
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Provider Business Mailing Address
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Address Line | 945 W MICHIGAN AVE STE 10C
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City | PENSACOLA
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State | FL
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Zip | 32505-2345
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Country | US
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Telephone | 850-912-6179
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Fax | 888-404-5528
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Authorized Official
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Title or Position | OWNER
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Name | ELIAS I BANUELOS
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Credential | M.D.
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Telephone | 850-912-6179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME97139
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License Number State | FL
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