1194994301 NPI number — STEPHEN BENCHO

Table of content: (NPI 1194994301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194994301 NPI number — STEPHEN BENCHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN BENCHO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194994301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37760-0327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-475-2657
Provider Business Mailing Address Fax Number:
865-475-2657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 W OLD ANDREW JOHNSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-475-2657
Provider Business Practice Location Address Fax Number:
865-475-2657
Provider Enumeration Date:
02/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BENCHO
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-475-2657

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0656630001 . This is a "PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3518221 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".