Provider Demographics
NPI:1649215310
Name:MELANCON, BENJY LEE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BENJY
Middle Name:LEE
Last Name:MELANCON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S DENTON ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-5326
Mailing Address - Country:US
Mailing Address - Phone:940-668-8746
Mailing Address - Fax:940-668-8746
Practice Address - Street 1:1201 S LINDSAY ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-5661
Practice Address - Country:US
Practice Address - Phone:940-736-6834
Practice Address - Fax:940-665-9265
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer