Provider Demographics
NPI:1053771907
Name:BELTEJAR-DIFUNTORUM, EVANGELINE
Entity type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:
Last Name:BELTEJAR-DIFUNTORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 KOENIG RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-7811
Mailing Address - Country:US
Mailing Address - Phone:775-324-0691
Mailing Address - Fax:775-324-1220
Practice Address - Street 1:4900 KOENIG RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-7811
Practice Address - Country:US
Practice Address - Phone:775-324-0691
Practice Address - Fax:775-324-1220
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV057Medicaid