Provider Demographics
NPI:1972355667
Name:MCCOY, BENJAMIN CLAYTON
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CLAYTON
Last Name:MCCOY
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 1:160 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2207
Mailing Address - Country:US
Mailing Address - Phone:303-590-8036
Mailing Address - Fax:
Practice Address - Street 1:6363 W 120TH AVE STE 310
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2406
Practice Address - Country:US
Practice Address - Phone:720-768-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist