Basic Information
| Provider Information | |||||||||
| NPI: | 1417909300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNECKE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | FRED | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | KT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENNECKE | ||||||||
| OtherFirstName: | ROBERT | ||||||||
| OtherMiddleName: | FRED | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | CDRS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 627 | ||||||||
| Address2: | |||||||||
| City: | SANDIA PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052860169 | ||||||||
| FaxNumber: | 5052565704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | 5052565704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 226300000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Kinesiotherapist |
No ID Information.