Provider Demographics
NPI:1760089304
Name:PERALTA, BUENAVENTURA (OTR/L)
Entity type:Individual
Prefix:
First Name:BUENAVENTURA
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 MILLIKEN AVE APT 7114
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8511
Mailing Address - Country:US
Mailing Address - Phone:909-528-2355
Mailing Address - Fax:
Practice Address - Street 1:1950 S MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-6723
Practice Address - Country:US
Practice Address - Phone:909-983-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4236224Z00000X
CA26834225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant