Provider Demographics
NPI:1497195416
Name:CROSE, BENJAMIN T (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:T
Last Name:CROSE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1124
Mailing Address - Country:US
Mailing Address - Phone:559-322-5345
Mailing Address - Fax:559-322-5041
Practice Address - Street 1:615 4TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1124
Practice Address - Country:US
Practice Address - Phone:559-322-5345
Practice Address - Fax:559-322-5041
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 39792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA119791Medicare UPIN