Basic Information
| Provider Information | |||||||||
| NPI: | 1568181022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENAVIDEZ | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | RODOLFO | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43368 GADSDEN AVE APT 150 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935346066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6615375932 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23845 MCBEAN PKWY | ||||||||
| Address2: | |||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913552083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612002000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2022 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 95213132 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.