Healthcare Provider Details

I. General information

NPI: 1801719661
Provider Name (Legal Business Name): BENIGNO ANTONIO OLIVARES LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29607 BARNES AVE
FORT GORDON GA
30905
US

IV. Provider business mailing address

3637 ALENE CIR
AUGUSTA GA
30906-4356
US

V. Phone/Fax

Practice location:
  • Phone: 706-262-5087
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015541
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: