=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922073584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE BENANDI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2006
-----------------------------------------------------
Last Update Date | 04/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1412 GAUDET DR
-----------------------------------------------------
City | MARRERO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70072-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-768-1995
-----------------------------------------------------
Fax | 504-533-0114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1412 GAUDET DR
-----------------------------------------------------
City | MARRERO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70072-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-768-1995
-----------------------------------------------------
Fax | 504-533-0114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------