Healthcare Provider Details

I. General information

NPI: 1639570757
Provider Name (Legal Business Name): MARK BENCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SPRING HILL DR STE 210
SPRING TX
77386-6025
US

IV. Provider business mailing address

500 SPRING HILL DR STE 210
SPRING TX
77386-6025
US

V. Phone/Fax

Practice location:
  • Phone: 888-485-5551
  • Fax:
Mailing address:
  • Phone: 888-485-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberB17613
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: