Provider Demographics
NPI:1518744390
Name:MILLER, BENJAMIN G
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
Last Name:MILLER
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 1:18826 PEPPERDINE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3904
Mailing Address - Country:US
Mailing Address - Phone:310-601-0029
Mailing Address - Fax:
Practice Address - Street 1:18826 PEPPERDINE DR
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3904
Practice Address - Country:US
Practice Address - Phone:310-601-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN682930164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse