Basic Information
Provider Information | |||||||||
NPI: | 1891728036 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUMPHERYS | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | RICH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2121 N 1700 W | ||||||||
Address2: |   | ||||||||
City: | LAYTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840418803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017734840 | ||||||||
FaxNumber: | 8015258702 | ||||||||
Practice Location | |||||||||
Address1: | 2121 N 1700 W | ||||||||
Address2: |   | ||||||||
City: | LAYTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840418803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017734840 | ||||||||
FaxNumber: | 8015258702 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 11/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4452 | AZ | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081P2900X | 6565196-1204 | UT | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.