Healthcare Provider Details

I. General information

NPI: 1134585391
Provider Name (Legal Business Name): BENJAMIN DYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 CONCHO DR
HENDERSON NV
89015-5240
US

IV. Provider business mailing address

249 CONCHO DR
HENDERSON NV
89015-5240
US

V. Phone/Fax

Practice location:
  • Phone: 702-757-8288
  • Fax:
Mailing address:
  • Phone: 702-757-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: