Healthcare Provider Details

I. General information

NPI: 1578967758
Provider Name (Legal Business Name): CHRISTOPHER BENEDICT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2014
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2739 GRANADA DR APT 1D
JACKSON MI
49202-5245
US

IV. Provider business mailing address

2739 GRANADA DR APT 1D
JACKSON MI
49202-5245
US

V. Phone/Fax

Practice location:
  • Phone: 248-760-3641
  • Fax:
Mailing address:
  • Phone: 248-760-3641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001373
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00200500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: