Provider Demographics
NPI:1073162095
Name:BENJAMIN, WICLIFF BERRIS
Entity Type:Individual
Prefix:
First Name:WICLIFF BERRIS
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10427 E IDAHO CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-7715
Mailing Address - Country:US
Mailing Address - Phone:602-326-7232
Mailing Address - Fax:489-264-7516
Practice Address - Street 1:10427 E IDAHO CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-7715
Practice Address - Country:US
Practice Address - Phone:602-326-7232
Practice Address - Fax:489-264-7516
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide