Healthcare Provider Details

I. General information

NPI: 1992202345
Provider Name (Legal Business Name): BENJAMIN JAMES LEIBOLD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BERCUT DRIVE SUITE B
SACRAMENTO CA
95811
US

IV. Provider business mailing address

9078 GEYSER PEAK WAY
SACRAMENTO CA
95829-1251
US

V. Phone/Fax

Practice location:
  • Phone: 916-443-2479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: