MEDICARE: BENCHMARK IOM, LLC

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	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1659731586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENCHMARK IOM, LLC

Provider Business Mailing Address
First Line	:	3020 CANTON ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75226-1605
Country	:	US
Telephone Number	:	972-403-1702
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 CANTON ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75226-1605
Country	:	US
Telephone Number	:	972-403-1702
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	DAVID WAYNE SMITH
Credential	:
Telephone Number	:	972-403-1702

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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Directions to “BENCHMARK IOM, LLC ” Practice Location

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