Provider Demographics
NPI:1295180172
Name:BENTON, TROY (LMT)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:BENTON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8083 SE 13TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6668
Mailing Address - Country:US
Mailing Address - Phone:269-254-0037
Mailing Address - Fax:
Practice Address - Street 1:8083 SE 13TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6668
Practice Address - Country:US
Practice Address - Phone:269-254-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22075172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist