Healthcare Provider Details

I. General information

NPI: 1023851565
Provider Name (Legal Business Name): BENJAMIN THOMAS KRUK INDEPENDENT DUTY COR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BENJAMIN THOMAS KRUK INDEPENDENT DUTY COR

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE BUILDING 14
APO AA
92124
US

IV. Provider business mailing address

3504 KELSEY ST
SAN DIEGO CA
92124-3516
US

V. Phone/Fax

Practice location:
  • Phone: 702-960-2719
  • Fax:
Mailing address:
  • Phone: 702-960-2719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: