Provider Demographics
NPI:1427101369
Name:BENACARE MEDICAL CENTER, INC
Entity type:Organization
Organization Name:BENACARE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAVIDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-373-8222
Mailing Address - Street 1:984 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3700
Mailing Address - Country:US
Mailing Address - Phone:909-373-8222
Mailing Address - Fax:877-803-0308
Practice Address - Street 1:984 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3700
Practice Address - Country:US
Practice Address - Phone:909-373-8222
Practice Address - Fax:877-803-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6396207Q00000X
CA20A8664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63960Medicaid
CAG68283Medicare UPIN
CAI08852Medicare UPIN
CAZZZ28742ZMedicare ID - Type Unspecified