Provider Demographics
NPI:1912472176
Name:WORRELL, BENJAMIN JOSEPH
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:WORRELL
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 1:101 E ALMA ST STE 304
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2290
Mailing Address - Country:US
Mailing Address - Phone:530-921-8854
Mailing Address - Fax:
Practice Address - Street 1:101 E ALMA ST STE 304
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2290
Practice Address - Country:US
Practice Address - Phone:530-859-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA9507155172A00000X
CA344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No172A00000XOther Service ProvidersDriver