Healthcare Provider Details

I. General information

NPI: 1467294538
Provider Name (Legal Business Name): BENJAMIN SPECHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SYCAMORE AVE
SIOUX FALLS SD
57110
US

IV. Provider business mailing address

PO BOX 194
LARCHWOOD IA
51241-0194
US

V. Phone/Fax

Practice location:
  • Phone: 605-367-7970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0812
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: