=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902860323
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN KEEN BENNER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 10/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 470-5 TOWN CENTER PLACE VILLAGE AT SANDHILL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-865-1211
-----------------------------------------------------
Fax | 803-865-1451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 HAY HILL CT
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29045-8239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-865-7763
-----------------------------------------------------
Fax | 803-865-1451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1333
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3329/T179
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------