Basic Information
Provider Information
NPI: 1164579322
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FESAGAIGA
FirstName: BENJAMIN
MiddleName: JACOB
NamePrefix: MR.
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 22917 ARCHIBALD AVE
Address2:  
City: CARSON
State: CA
PostalCode: 907454716
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1975 LONG BEACH BLVD
Address2:  
City: LONG BEACH
State: CA
PostalCode: 908065501
CountryCode: US
TelephoneNumber: 5625999401
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/03/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163WP0808X519452CAY Nursing Service ProvidersRegistered NursePsych/Mental Health

No ID Information.


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