Provider Demographics
NPI:1114589553
Name:BENOIT, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BENOIT
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 1:61110 BROOKHOLLOW DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2938
Mailing Address - Country:US
Mailing Address - Phone:603-831-8127
Mailing Address - Fax:
Practice Address - Street 1:999 SW DISK DR STE 105
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3060
Practice Address - Country:US
Practice Address - Phone:541-639-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT-21681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist