Healthcare Provider Details

I. General information

NPI: 1194475434
Provider Name (Legal Business Name): JUSTINE BENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

1722 COLLEGE MANOR DR
GOSHEN IN
46526-5150
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-2679
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number37003452A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37003452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: