Provider Demographics
NPI:1073974523
Name:BENJAMIN, PETER (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1261 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1237
Practice Address - Country:US
Practice Address - Phone:734-649-2853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer