Provider Demographics
NPI:1003161274
Name:IGBOELI, BENSON
Entity Type:Individual
Prefix:
First Name:BENSON
Middle Name:
Last Name:IGBOELI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BENSON
Other - Middle Name:
Other - Last Name:IGBOELI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:829 SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6092
Mailing Address - Country:US
Mailing Address - Phone:972-262-5828
Mailing Address - Fax:972-262-5828
Practice Address - Street 1:829 SPRINGWOOD DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6092
Practice Address - Country:US
Practice Address - Phone:972-262-5828
Practice Address - Fax:972-262-5828
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000000000000251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization