Healthcare Provider Details

I. General information

NPI: 1932820149
Provider Name (Legal Business Name): BENJAMIN BUHL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 MADORA AVE
DOUGLAS WY
82633-3057
US

IV. Provider business mailing address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-2846
  • Fax: 307-358-1144
Mailing address:
  • Phone: 307-358-2846
  • Fax: 307-358-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: