Provider Demographics
NPI:1023545027
Name:BENJAMIN, EDDIE R JR (LPN)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:R
Last Name:BENJAMIN
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 TULSA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-5513
Mailing Address - Country:US
Mailing Address - Phone:619-997-8952
Mailing Address - Fax:
Practice Address - Street 1:1791 ALUM CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207
Practice Address - Country:US
Practice Address - Phone:614-445-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162941164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0129422Medicaid