Provider Demographics
NPI:1043609753
Name:BENCOMO, LOWELL MONTANA (ATC)
Entity Type:Individual
Prefix:MR
First Name:LOWELL
Middle Name:MONTANA
Last Name:BENCOMO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 S LOCUST ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5789
Mailing Address - Country:US
Mailing Address - Phone:575-521-4188
Mailing Address - Fax:
Practice Address - Street 1:2404 S LOCUST ST STE 5
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5789
Practice Address - Country:US
Practice Address - Phone:575-521-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6972255A2300X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program