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General NPI Number Information
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NPI Number | 1699964676
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Entity Type | Individual
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Provider Name | MR. CORRY BENSON HAXTON
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Gender | Male
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 10/16/2007
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Provider Practice Location Address
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Address Line | 6122 FIRESIDE DR APT B
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City | CENTERVILLE
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State | OH
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Zip | 45459-2035
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Country | US
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Telephone | 937-723-7503
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Fax |
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Provider Business Mailing Address
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Address Line | 6122 FIRESIDE DR APT B
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City | CENTERVILLE
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State | OH
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Zip | 45459-2035
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Country | US
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Telephone | 937-723-7503
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | PTA00518
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License Number State | OH
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