Healthcare Provider Details

I. General information

NPI: 1568008902
Provider Name (Legal Business Name): TRACI BENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 N MARTIN LUTHER KING BLVD SUITE 105B
N LAS VEGAS NV
89032
US

IV. Provider business mailing address

8936 SPANISH RIDGE AVE CREDENTIALING
LAS VEGAS NV
89148
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-0909
  • Fax: 702-724-1978
Mailing address:
  • Phone: 702-998-2816
  • Fax: 702-998-2991

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: