Healthcare Provider Details

I. General information

NPI: 1003064718
Provider Name (Legal Business Name): BENJAMIN THEM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 10/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10002 SAN JUAN ST APT 4
SPRING VALLEY CA
91977-1635
US

IV. Provider business mailing address

10002 SAN JUAN ST #4
SPRING VALLEY CA
91977-1635
US

V. Phone/Fax

Practice location:
  • Phone: 619-346-5854
  • Fax:
Mailing address:
  • Phone: 619-346-5854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: