Provider Demographics
NPI:1487074167
Name:BANUELOS FAMILY CLINIC
Entity type:Organization
Organization Name:BANUELOS FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:I
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-490-6727
Mailing Address - Street 1:945 W MICHIGAN AVE STE 10C
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-2346
Mailing Address - Country:US
Mailing Address - Phone:850-490-6727
Mailing Address - Fax:
Practice Address - Street 1:945 W MICHIGAN AVE STE 10C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-2346
Practice Address - Country:US
Practice Address - Phone:850-490-6727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty