Healthcare Provider Details

I. General information

NPI: 1336385665
Provider Name (Legal Business Name): BENJAMIN ANTIG JAVIER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 JOY CT
SAN MARCOS CA
92078-4100
US

IV. Provider business mailing address

787 JOY CT
SAN MARCOS CA
92078-4100
US

V. Phone/Fax

Practice location:
  • Phone: 760-304-4207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRHF 71939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: