MEDICARE: BEN SAMBORN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	5502003246	MI

General Provider Information

NPI Number	:	1043649726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEN SAMBORN

Provider Business Mailing Address
First Line	:	4295 BALSAM CIR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49696-8328
Country	:	US
Telephone Number	:	989-280-4753
Fax Number	:	231-947-1250

Provider Business Practice Location Address
First Line	:	4295 BALSAM CIR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49696-8328
Country	:	US
Telephone Number	:	989-280-4753
Fax Number	:	231-947-1250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	11/04/2013

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