Provider Demographics
NPI:1619733342
Name:KONG, BENJAMIN (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:KONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 GIBBONS PKWY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2247
Mailing Address - Country:US
Mailing Address - Phone:916-468-8845
Mailing Address - Fax:
Practice Address - Street 1:3900 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6647
Practice Address - Country:US
Practice Address - Phone:916-481-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist