Healthcare Provider Details

I. General information

NPI: 1649680208
Provider Name (Legal Business Name): SUZANNE BENJAMIN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S COLUMBIA RD
GRAND FORKS ND
58201-4012
US

IV. Provider business mailing address

1300 S COLUMBIA RD
GRAND FORKS ND
58201-4012
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6771
  • Fax: 701-780-6088
Mailing address:
  • Phone: 701-780-6771
  • Fax: 701-780-6088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: