Healthcare Provider Details

I. General information

NPI: 1902009053
Provider Name (Legal Business Name): BENJAMIN DARTER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR FORT SAM HOUSTON
SAN ANTONIO TX
78234-4501
US

IV. Provider business mailing address

12900 E LOOP 1604 N APT 532
UNIVERSAL CITY TX
78148-3175
US

V. Phone/Fax

Practice location:
  • Phone: 210-619-6190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03513
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: