Basic Information
| Provider Information | |||||||||
| NPI: | 1275635500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENITEZ-QUINONES | ||||||||
| FirstName: | ARELIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENITEZ | ||||||||
| OtherFirstName: | ARELIS | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 210 1ST STREET, P.O. BOX 290 | ||||||||
| Address2: | |||||||||
| City: | WANBLEE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054625650 | ||||||||
| FaxNumber: | 6054626631 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | WANBLEE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6054625650 | ||||||||
| FaxNumber: | 6054626631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 5540040 | 05 | SD | MEDICAID | 15481 | 01 | PR | LICENSE | OTHER | PHS000 | 01 | UPIN | OTHER |