Provider Demographics
NPI:1962004838
Name:POTVIN, BENJAMYN LAWRENCE (SF-IDC, CPHT, NREMT)
Entity Type:Individual
Prefix:
First Name:BENJAMYN
Middle Name:LAWRENCE
Last Name:POTVIN
Suffix:
Gender:M
Credentials:SF-IDC, CPHT, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 GUADALCANAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92140-0001
Mailing Address - Country:US
Mailing Address - Phone:619-524-4404
Mailing Address - Fax:619-524-4422
Practice Address - Street 1:3400 GUADALCANAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-0001
Practice Address - Country:US
Practice Address - Phone:619-524-4404
Practice Address - Fax:619-524-4422
Is Sole Proprietor?:No
Enumeration Date:2020-11-14
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3223966146N00000X
TX30045107183700000X
CA1710I1002X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No183700000XPharmacy Service ProvidersPharmacy Technician
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman