Healthcare Provider Details

I. General information

NPI: 1730425281
Provider Name (Legal Business Name): BENJAMIN JAMES COLVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2013
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 ROWENA ST
MONTGOMERY LA
71454-6313
US

IV. Provider business mailing address

105 COMMANCHE TRL
PINEVILLE LA
71360-4403
US

V. Phone/Fax

Practice location:
  • Phone: 318-646-3000
  • Fax: 318-646-3003
Mailing address:
  • Phone: 318-663-4914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07366
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number120031
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: