Basic Information
| Provider Information | |||||||||
| NPI: | 1891126603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 E 18TH ST | ||||||||
| Address2: | APT 4 | ||||||||
| City: | SPENCER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192150656 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 1ST AVE E | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPENCER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122627511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2013 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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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 | 2255A2300X | 000831 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.