1427147784 NPI number — C RIC BENEDETTI DPT

Table of content: C RIC BENEDETTI DPT (NPI 1427147784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427147784 NPI number — C RIC BENEDETTI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEDETTI
Provider First Name:
C
Provider Middle Name:
RIC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENEDETTI
Provider Other First Name:
C. RIC
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT, MBA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1427147784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2844
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83206-2844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-4800
Provider Business Mailing Address Fax Number:
208-233-4887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 W QUINN RD
Provider Second Line Business Practice Location Address:
560 MEMORIAL DR
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-4800
Provider Business Practice Location Address Fax Number:
208-233-4887
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT131 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 650009795 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T1542 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010008588 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 004396600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com