Healthcare Provider Details

I. General information

NPI: 1659565455
Provider Name (Legal Business Name): BENJAMIN M KROLL SW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 RAYMAC RD SW POLK MS
ALBUQUERQUE NM
87105-6843
US

IV. Provider business mailing address

2220 RAYMAC RD SW POLK MS
ALBUQUERQUE NM
87105-6843
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-6494
  • Fax:
Mailing address:
  • Phone: 505-877-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI 4517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: