Healthcare Provider Details

I. General information

NPI: 1164976320
Provider Name (Legal Business Name): JONATHAN BENZING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

IV. Provider business mailing address

2300 WESTERN AVE
MANITOWOC WI
54220-3712
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-3100
  • Fax: 920-320-5114
Mailing address:
  • Phone: 920-320-3100
  • Fax: 920-320-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13395-24
License Number StateWI

VII. Legacy identifiers

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

# 1
Identifier1700998697
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: