Provider Demographics
NPI:1992914915
Name:POWELL, BENJAMIN J
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 WARMLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-4203
Mailing Address - Country:US
Mailing Address - Phone:760-721-2781
Mailing Address - Fax:
Practice Address - Street 1:2821 OCEANSIDE BLVD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-4800
Practice Address - Country:US
Practice Address - Phone:760-721-2781
Practice Address - Fax:760-721-9571
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3720OtherCAS REGISTATION NUMBER