Provider Demographics
NPI:1437676467
Name:STACHOWIAK, BENJAMIN STANLEY (ATC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:STANLEY
Last Name:STACHOWIAK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MCENTIRE LN SW APT E11
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-7630
Mailing Address - Country:US
Mailing Address - Phone:630-401-7180
Mailing Address - Fax:
Practice Address - Street 1:2506 DANVILLE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-4232
Practice Address - Country:US
Practice Address - Phone:256-350-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer