Healthcare Provider Details

I. General information

NPI: 1407710726
Provider Name (Legal Business Name): BENJAMIN SO RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 CAMINO DEL RIO S STE 100
SAN DIEGO CA
92108-3822
US

IV. Provider business mailing address

5180 DE BURN DR
SAN DIEGO CA
92105-5411
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-8923
  • Fax: 858-649-6012
Mailing address:
  • Phone: 619-808-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-380229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: