1548636780 NPI number — MIRANDA KAY BENSON MAT, AT, ATC

Table of content: MIRANDA KAY BENSON MAT, AT, ATC (NPI 1548636780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548636780 NPI number — MIRANDA KAY BENSON MAT, AT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENSON
Provider First Name:
MIRANDA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MAT, AT, ATC
Provider Gender Code:
F

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:
1548636780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 N 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63435-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-639-9272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301-2670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-228-5432
Provider Business Practice Location Address Fax Number:
217-228-5604
Provider Enumeration Date:
08/11/2015

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: 2255A2300X , with the licence number:  096.004631 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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