Provider Demographics
NPI:1497942700
Name:BENN, MELINDA S
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:S
Last Name:BENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1535
Mailing Address - Country:US
Mailing Address - Phone:810-630-0555
Mailing Address - Fax:
Practice Address - Street 1:6005 MILLER RD
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1535
Practice Address - Country:US
Practice Address - Phone:810-630-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
00710OtherMEDICARE PLUS BLUE
60054OtherAETNA
98999OtherUNITED HEALTH CARE
0M58150OtherMEDICARE
61271OtherMUTUAL OF OMAHA
P97868OtherBLUE CARE NETWORK