Provider Demographics
NPI:1437939360
Name:THORNBURY, BENJAMIN WILLIAM
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:THORNBURY
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 1:3636 N. FIRST ST. SUITE 162,124,112
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726
Mailing Address - Country:US
Mailing Address - Phone:559-476-2166
Mailing Address - Fax:
Practice Address - Street 1:3636 N. FIRST ST. SUITE 162,124,112
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-476-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator