Healthcare Provider Details

I. General information

NPI: 1912534603
Provider Name (Legal Business Name): STEVE BENNETHUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 104A DUFF AVE
AMES IA
50010-5001
US

IV. Provider business mailing address

703 104A DUFF AVE
AMES IA
50010-6353
US

V. Phone/Fax

Practice location:
  • Phone: 515-686-8026
  • Fax:
Mailing address:
  • Phone: 515-686-8026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number088585
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: