Provider Demographics
NPI:1629833975
Name:BENNINGHOVEN, DEANE (CH, CI)
Entity Type:Individual
Prefix:
First Name:DEANE
Middle Name:
Last Name:BENNINGHOVEN
Suffix:
Gender:M
Credentials:CH, CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1105
Mailing Address - Country:US
Mailing Address - Phone:253-229-9932
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 402
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4454
Practice Address - Country:US
Practice Address - Phone:253-229-9932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHP60959702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist