MEDICARE: BENJAMIN MICHAEL WIECHMAN MSOT

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1619392115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN MICHAEL WIECHMAN MSOT

Provider Business Mailing Address
First Line	:	1350 FAIRFAX ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-2527
Country	:	US
Telephone Number	:	785-221-1236
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 FAIRFAX ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-2527
Country	:	US
Telephone Number	:	785-221-1236
Fax Number	:

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

Provider Enumeration Date	:	02/20/2014
Last Update Date	:	02/20/2014

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