Healthcare Provider Details

I. General information

NPI: 1730720251
Provider Name (Legal Business Name): BENJAMIN JOHN KAKALLIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2019
Last Update Date: 10/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24300 E SMOKY HILL RD
AURORA CO
80016-1387
US

IV. Provider business mailing address

25300 E ABERDEEN DR
AURORA CO
80016-6205
US

V. Phone/Fax

Practice location:
  • Phone: 303-680-1772
  • Fax:
Mailing address:
  • Phone: 562-858-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0013968
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: