Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN1001X | Nutrition | 22978 | CA |
Y | 111NR0400X | Rehabilitation Chiropractor | 22978 | CA |
NPI | 1164753174 |
---|---|
Provider Name | Dr. Ben D. Carlson |
First Address | Fountain Valley, CA 92708 |
Second Address | Fountain Valley, CA 92708 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2010 |
Last Update Date | 15/01/2010 |