Provider Demographics
NPI:1962822866
Name:MUNFORD, BEN JR
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:MUNFORD
Suffix:JR
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 1:3371 THISTLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7610
Mailing Address - Country:US
Mailing Address - Phone:951-260-7009
Mailing Address - Fax:
Practice Address - Street 1:245 N MURRAY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5528
Practice Address - Country:US
Practice Address - Phone:951-663-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program