Healthcare Provider Details

I. General information

NPI: 1902938350
Provider Name (Legal Business Name): BENJAMEN P. CLANCY L.AC, DIPL.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4169 WESTPORT RD SUITE 124
LOUISVILLE KY
40207-2747
US

IV. Provider business mailing address

4169 WESTPORT RD SUITE 124
LOUISVILLE KY
40207-2747
US

V. Phone/Fax

Practice location:
  • Phone: 502-710-9088
  • Fax:
Mailing address:
  • Phone: 502-710-9088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC026
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: