Provider Demographics
NPI:1639570757
Name:BENCH, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BENCH
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 1:500 SPRING HILL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-6025
Mailing Address - Country:US
Mailing Address - Phone:888-485-5551
Mailing Address - Fax:
Practice Address - Street 1:500 SPRING HILL DR STE 210
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-6025
Practice Address - Country:US
Practice Address - Phone:888-485-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB17613171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor