Basic Information
Provider Information
NPI: 1023111929
EntityType: 2
ReplacementNPI:  
OrganizationName: BENTON HEALTH CARE, LLC
LastName:  
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Mailing Information
Address1: PO BOX 9150
Address2:  
City: PADUCAH
State: KY
PostalCode: 420029150
CountryCode: US
TelephoneNumber: 2707449600
FaxNumber: 2707440834
Practice Location
Address1: 414 EAST 12TH STREET
Address2:  
City: BENTON
State: KY
PostalCode: 42025
CountryCode: US
TelephoneNumber: 2705273900
FaxNumber: 2705273901
Other Information
ProviderEnumerationDate: 09/06/2006
LastUpdateDate: 04/20/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FIESSINGER
AuthorizedOfficialFirstName: JASON
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: FAMILY NURSE PRACTITIONER
AuthorizedOfficialTelephone: 2705273900
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: APRN
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XKY 3122PKYY193400000X SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
710001604005KY MEDICAID


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