Provider Demographics
NPI:1417473034
Name:ADOM, BEN ARNOLD (NP)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:ARNOLD
Last Name:ADOM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 N PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-3145
Mailing Address - Fax:909-580-2165
Practice Address - Street 1:12021 JACARANDA AVE STE 101
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4978
Practice Address - Country:US
Practice Address - Phone:760-956-5057
Practice Address - Fax:760-947-2057
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95042846163W00000X
CA95021179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417473034OtherFAMILY PRACTICE