Basic Information
| Provider Information | |||||||||
| NPI: | 1154303493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TACHERON | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3269 N STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282634722 | ||||||||
| FaxNumber: | 9282634794 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 SANTA ROSA DR | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286818570 | ||||||||
| FaxNumber: | 9286818569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | D35409 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | D0035409 | MD | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 47720 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 884589 | 05 | AZ | MEDICAID | 47720 | 01 | AZ | STATE MEDICAL LICENSE | OTHER | DR.0050597 | 01 | CO | STATE MEDICAL LICENSE | OTHER |