Basic Information
| Provider Information | |||||||||
| NPI: | 1982712626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | DONELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 711185 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841711185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019423311 | ||||||||
| FaxNumber: | 8019425955 | ||||||||
| Practice Location | |||||||||
| Address1: | 9484 W. LAKE MEAD BLVD | ||||||||
| Address2: | STE. 8-10 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891348339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022437744 | ||||||||
| FaxNumber: | 7022439688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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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 | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2261 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1149363 | 01 | TX | LICENSE # | OTHER |