Healthcare Provider Details

I. General information

NPI: 1376923730
Provider Name (Legal Business Name): BENJAMIN KUSTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 DIAMOND RDG
JEFFERSON CITY MO
65109-6896
US

IV. Provider business mailing address

302 RIDGEWAY DR
JEFFERSON CITY MO
65109-0786
US

V. Phone/Fax

Practice location:
  • Phone: 573-761-9360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2002022537
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: