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General NPI Number Information
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NPI Number | 1972206092
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Entity Type | Individual
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Provider Name | BENJAMIN BRUCE KOFOED
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Gender | Male
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Dates
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Enumeration Date | 03/27/2023
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Last Update Date | 03/27/2023
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Provider Practice Location Address
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Address Line | 49 JESSE HILL JR DR SE
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City | ATLANTA
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State | GA
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Zip | 30303-3049
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Country | US
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Telephone | 404-778-7777
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Fax |
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Provider Business Mailing Address
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Address Line | 4603 MINNEHAHA AVE UNIT 526
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City | MINNEAPOLIS
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State | MN
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Zip | 55406-4279
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Country | US
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Telephone | 952-807-7305
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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