=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740069657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAVON M. BENNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 N DEFIANCE ST
-----------------------------------------------------
City | STRYKER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43557-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-344-5118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 N DEFIANCE ST # 544
-----------------------------------------------------
City | STRYKER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43557-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-344-5118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------