Provider Demographics
NPI:1144827601
Name:BENISON-GLOVER, DOLORES MARY (LVN)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:MARY
Last Name:BENISON-GLOVER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 E FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4296
Mailing Address - Country:US
Mailing Address - Phone:714-953-9373
Mailing Address - Fax:714-418-4634
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:714-418-4634
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN247827324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility