Healthcare Provider Details

I. General information

NPI: 1811129745
Provider Name (Legal Business Name): BENTON FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 BURT BLVD
BENTON LA
71006-4900
US

IV. Provider business mailing address

188 BURT BLVD
BENTON LA
71006-4900
US

V. Phone/Fax

Practice location:
  • Phone: 318-965-1000
  • Fax:
Mailing address:
  • Phone: 318-965-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD09509R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04759
License Number StateLA

VIII. Authorized Official

Name: MS. KELLEY NOVAK
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 318-965-1000