Healthcare Provider Details

I. General information

NPI: 1508303017
Provider Name (Legal Business Name): BENJAMIN BUMGUARDNER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2017
Last Update Date: 09/06/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4438 SH 6 S SUITE 104
COLLEGE STATION TX
77845-7452
US

IV. Provider business mailing address

4438 SH 6 S #104
COLLEGE STATION TX
77845
US

V. Phone/Fax

Practice location:
  • Phone: 979-398-2787
  • Fax:
Mailing address:
  • Phone: 325-660-3266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number13391
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: