=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194759381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L.A. BEBENSEE DO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 10/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 CHESTNUT ST SUITE 108
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-471-4445
-----------------------------------------------------
Fax | 479-471-2026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 CHESTNUT ST SUITE 108
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-471-4445
-----------------------------------------------------
Fax | 479-471-2026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. LONETTE ANN BEBENSEE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 479-471-4445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | E4053
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------