Provider Demographics
NPI:1003180381
Name:BENGSTON FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:BENGSTON FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:SUSANNE
Authorized Official - Last Name:BENGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:863-675-0550
Mailing Address - Street 1:870 W HICKPOCHEE AVE
Mailing Address - Street 2:SSUITE 1700
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33935-4313
Mailing Address - Country:US
Mailing Address - Phone:863-675-0550
Mailing Address - Fax:863-675-0553
Practice Address - Street 1:870 W HICKPOCHEE AVE
Practice Address - Street 2:SSUITE 1700
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4313
Practice Address - Country:US
Practice Address - Phone:863-675-0550
Practice Address - Fax:863-675-0553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-03
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2209102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302076200Medicaid
FL302076200Medicaid