Healthcare Provider Details

I. General information

NPI: 1326596792
Provider Name (Legal Business Name): BENJAMIN SUTPHIN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 FORDHAM DR SUITE 102
FAYETTEVILLE NC
28304-3773
US

IV. Provider business mailing address

1991 FORDHAM DR SUITE 102
FAYETTEVILLE NC
28304-3773
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-4653
  • Fax:
Mailing address:
  • Phone: 910-484-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: