Provider Demographics
NPI:1467215970
Name:CARRASCO, BENJAMIN BRADY GARCIA
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRADY GARCIA
Last Name:CARRASCO
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 1:1031 WATERLOO RD
Mailing Address - Street 2:ATTN: SUD
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205
Mailing Address - Country:US
Mailing Address - Phone:408-603-0488
Mailing Address - Fax:
Practice Address - Street 1:1031 WATERLOO RD
Practice Address - Street 2:ATTN: SUD
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205
Practice Address - Country:US
Practice Address - Phone:408-603-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator