Provider Demographics
NPI:1205096559
Name:LAXAMANA, BENJAMIN CORTEZ (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CORTEZ
Last Name:LAXAMANA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 DALE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9472
Mailing Address - Country:US
Mailing Address - Phone:707-685-6077
Mailing Address - Fax:707-514-7178
Practice Address - Street 1:342 DALE CT
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9472
Practice Address - Country:US
Practice Address - Phone:707-685-6077
Practice Address - Fax:707-514-7178
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28375OtherPHYSICAL THERAPY BOARD OF CALIFORNIA