Healthcare Provider Details

I. General information

NPI: 1831576800
Provider Name (Legal Business Name): AUTUMN BENSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LOUISVILLE AVE
MONROE LA
71201-6021
US

IV. Provider business mailing address

130 DESIARD ST SUITE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-807-1500
  • Fax: 318-807-1504
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2567
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: