Healthcare Provider Details

I. General information

NPI: 1053309005
Provider Name (Legal Business Name): BENJAMIN P. LLANES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9580 BLACK MOUNTAIN RD SUITE J
SAN DIEGO CA
92126-4522
US

IV. Provider business mailing address

9580 BLACK MOUNTAIN RD SUITE J
SAN DIEGO CA
92126-4522
US

V. Phone/Fax

Practice location:
  • Phone: 858-536-8952
  • Fax: 858-536-8951
Mailing address:
  • Phone: 858-536-8952
  • Fax: 858-536-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8782T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: