Basic Information
| Provider Information | |||||||||
| NPI: | 1144827601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENISON-GLOVER | ||||||||
| FirstName: | DOLORES | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
| FaxNumber: | 7144184634 | ||||||||
| Practice Location | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
| FaxNumber: | 7144184634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | VN247827 | CA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.