Provider Demographics
NPI:1093465908
Name:WALDER, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:WALDER
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 1:13703 LITTLE POND RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-5841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO ST STE H2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2106
Practice Address - Country:US
Practice Address - Phone:505-557-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8595225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist