Provider Demographics
NPI:1417909300
Name:BENNECKE, ROBERT FRED JR (KT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:FRED
Last Name:BENNECKE
Suffix:JR
Gender:M
Credentials:KT
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:FRED
Other - Last Name:BENNECKE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:CDRS
Mailing Address - Street 1:PO BOX 627
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047
Mailing Address - Country:US
Mailing Address - Phone:505-286-0169
Mailing Address - Fax:505-256-5704
Practice Address - Street 1:1501 SAN PEDRO SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-5704
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist