Provider Demographics
NPI:1285038950
Name:BENJAMIN COREY
Entity Type:Organization
Organization Name:BENJAMIN COREY
Other - Org Name:BENJAMIN COREY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:FREDRIC
Authorized Official - Last Name:COREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-755-0003
Mailing Address - Street 1:65 PINE AVE # 360
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4718
Mailing Address - Country:US
Mailing Address - Phone:626-755-0003
Mailing Address - Fax:
Practice Address - Street 1:17120 RIDGE PARK DR
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-755-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARW8585OtherCCBADC