Healthcare Provider Details

I. General information

NPI: 1164445433
Provider Name (Legal Business Name): LUIS ALFONSO BENAVENTE CHENHALLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE SUITE 340
ELKHART IN
46514-2477
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS SUITE 230
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-3317
  • Fax: 574-293-3523
Mailing address:
  • Phone: 574-251-2100
  • Fax: 574-251-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01068947A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: