Provider Demographics
NPI:1790990265
Name:MADRID, BENJAMIN CASTILLO JR (OTRL)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CASTILLO
Last Name:MADRID
Suffix:JR
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:
Other - Last Name:MADRID
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:OTRL
Mailing Address - Street 1:1234 AGATE ST
Mailing Address - Street 2:APT D
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2314
Mailing Address - Country:US
Mailing Address - Phone:310-508-0624
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:213-226-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2240225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist