Basic Information
| Provider Information | |||||||||
| NPI: | 1659675346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7601 LIONS GATE PKWY | ||||||||
| Address2: | |||||||||
| City: | DAVISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484233195 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1235 S CENTER RD STE 12 | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485091700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107438820 | ||||||||
| FaxNumber: | 8107435908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 5502003080 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.