Provider Demographics
NPI:1326764044
Name:BENESRT3
Entity Type:Organization
Organization Name:BENESRT3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. DO D. PSC
Authorized Official - Prefix:
Authorized Official - First Name:NANTUME-JANET:
Authorized Official - Middle Name:
Authorized Official - Last Name:KABANDA,BENEFICIARY
Authorized Official - Suffix:
Authorized Official - Credentials:DR DO D PSC
Authorized Official - Phone:732-874-0156
Mailing Address - Street 1:C/O 8 LOCUST STREET #1R
Mailing Address - Street 2:
Mailing Address - City:CARTERET.
Mailing Address - State:NJ
Mailing Address - Zip Code:07008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:C/O 8 LOCUST STREET 1R
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008
Practice Address - Country:US
Practice Address - Phone:732-874-0156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1164048138OtherMENTAL HEALTH SPECIALIST
NJ1417598418Medicaid