Provider Demographics
NPI:1669680856
Name:BENTON MEDICAL EQUIPMENT, INC.
Entity Type:Organization
Organization Name:BENTON MEDICAL EQUIPMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:650-625-1000
Mailing Address - Street 1:1145 TERRA BELLA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-1831
Mailing Address - Country:US
Mailing Address - Phone:650-625-1000
Mailing Address - Fax:650-625-1133
Practice Address - Street 1:2601 GARCIA AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1111
Practice Address - Country:US
Practice Address - Phone:650-625-1000
Practice Address - Fax:650-625-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHMDRL 44407332B00000X, 332BC3200X, 332BX2000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ428502OtherBLUESHIELD
CAVENXXXN050892OtherAETNA
CAZZZ428502OtherBLUESHIELD