1457743239 NPI number — MATTHEW BOYD BENNION DPT

Table of content: MATTHEW BOYD BENNION DPT (NPI 1457743239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457743239 NPI number — MATTHEW BOYD BENNION DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNION
Provider First Name:
MATTHEW
Provider Middle Name:
BOYD
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:
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:
1457743239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 493396
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96049-3396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-221-9952
Provider Business Mailing Address Fax Number:
530-221-9910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
844 BRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COLUSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95932-2867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-458-7770
Provider Business Practice Location Address Fax Number:
530-458-7735
Provider Enumeration Date:
03/03/2015

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: 225100000X , with the licence number:  PT42294 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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