Basic Information
| Provider Information | |||||||||
| NPI: | 1174800171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 654 LUCILLE AVE | ||||||||
| Address2: | 103 | ||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93210 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 24511 W JAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | COALINGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599354300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 724688 | CA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 20910 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.