Provider Demographics
NPI:1609328632
Name:BRETTELL, BENJMAIN
Entity Type:Individual
Prefix:
First Name:BENJMAIN
Middle Name:
Last Name:BRETTELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2631
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2631
Mailing Address - Country:US
Mailing Address - Phone:307-733-7946
Mailing Address - Fax:
Practice Address - Street 1:510 S CACHE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8693
Practice Address - Country:US
Practice Address - Phone:307-733-7946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator