Healthcare Provider Details

I. General information

NPI: 1558171900
Provider Name (Legal Business Name): BENJAMIN M GRANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

6801 LEISURE TOWN RD APT 120
VACAVILLE CA
95688-9446
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-9961
  • Fax:
Mailing address:
  • Phone: 918-207-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: