Healthcare Provider Details

I. General information

NPI: 1073384574
Provider Name (Legal Business Name): BENTON FURNITURE SHARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 MARION ST SE STE C
ALBANY OR
97322-3889
US

IV. Provider business mailing address

PO BOX 2224
CORVALLIS OR
97339-2224
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-9511
  • Fax:
Mailing address:
  • Phone: 541-754-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MICHELLE MADDUX-ROBINSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-730-2421