Healthcare Provider Details

I. General information

NPI: 1790093987
Provider Name (Legal Business Name): BRADY BENJAMIN ELLIOTT CPED, CFO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5923 CLARK RD STE C
PARADISE CA
95969
US

IV. Provider business mailing address

5923 CLARK RD STE C
PARADISE CA
95969
US

V. Phone/Fax

Practice location:
  • Phone: 530-872-3710
  • Fax: 530-872-7234
Mailing address:
  • Phone: 530-872-3710
  • Fax: 530-872-7234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: