MEDICARE: MR. BENSON IKENNA EJINDU

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1235422858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENSON IKENNA EJINDU

Provider Business Mailing Address
First Line	:	4430 OAKBURN DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-1695
Country	:	US
Telephone Number	:	704-906-2470
Fax Number	:	704-733-9771

Provider Business Practice Location Address
First Line	:	8305 UNIVERSITY EXEC PARK DR
Second Line	:	SUITE 340
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1361
Country	:	US
Telephone Number	:	704-733-9771
Fax Number	:	704-733-9771

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

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	05/17/2011

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