Provider Demographics
NPI:1730720251
Name:KAKALLIS, BENJAMIN JOHN (PTA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:KAKALLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25300 E ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-6205
Mailing Address - Country:US
Mailing Address - Phone:562-858-8930
Mailing Address - Fax:
Practice Address - Street 1:24300 E SMOKY HILL RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-1387
Practice Address - Country:US
Practice Address - Phone:303-680-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00139682081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine