Healthcare Provider Details

I. General information

NPI: 1528089562
Provider Name (Legal Business Name): BENJAMIN TABOR RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VETERANS AVE
BILOXI MS
39531-2410
US

IV. Provider business mailing address

15925 MCCLELLAN RD
BILOXI MS
39532-9334
US

V. Phone/Fax

Practice location:
  • Phone: 228-523-5514
  • Fax:
Mailing address:
  • Phone: 228-396-6036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: