Provider Demographics
NPI:1255764858
Name:VALLEJO, BENJAMIN (ABO & NCLE)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:ABO & NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 DEL AMO BLVD
Mailing Address - Street 2:SUITE #203
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-214-0811
Mailing Address - Fax:310-793-4658
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:SUITE #203
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-214-0811
Practice Address - Fax:310-793-4658
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL6458156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician