Provider Demographics
NPI:1477658755
Name:BENTON, CRAIG J (DC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:J
Last Name:BENTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33953-2903
Mailing Address - Country:US
Mailing Address - Phone:941-743-9904
Mailing Address - Fax:941-743-9905
Practice Address - Street 1:687 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33953-2903
Practice Address - Country:US
Practice Address - Phone:941-743-9904
Practice Address - Fax:941-743-9905
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7982111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53972ZOtherMEDICARE ID
FL53972ZOtherMEDICARE ID
FLU84503Medicare UPIN