Basic Information
| Provider Information | |||||||||
| NPI: | 1770593535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNION | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 BETHLEHEM RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035614113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034440111 | ||||||||
| FaxNumber: | 6034440473 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 BETHLEHEM RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035614113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034440111 | ||||||||
| FaxNumber: | 6034440473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0487 | NH | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 30410309 | 05 | NH | MEDICAID |