Provider Demographics
NPI:1619278967
Name:FRIES, BENTA JEAN
Entity Type:Individual
Prefix:MS
First Name:BENTA
Middle Name:JEAN
Last Name:FRIES
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 1:7055 N MAPLE AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8012
Mailing Address - Country:US
Mailing Address - Phone:559-432-7199
Mailing Address - Fax:559-765-4405
Practice Address - Street 1:7055 N MAPLE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8012
Practice Address - Country:US
Practice Address - Phone:559-432-7199
Practice Address - Fax:559-765-4405
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACFM017901744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1130740001Medicare NSC