Provider Demographics
NPI:1720655459
Name:CARLSON, BENJAMIN JOSH (CPO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSH
Last Name:CARLSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W STE 301
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3373
Mailing Address - Country:US
Mailing Address - Phone:801-702-9191
Mailing Address - Fax:877-326-3388
Practice Address - Street 1:975 N MAIN ST STE 3A
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2200
Practice Address - Country:US
Practice Address - Phone:385-377-3833
Practice Address - Fax:877-326-3388
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO03568222Z00000X, 224P00000X
225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter