Provider Demographics
NPI:1689960502
Name:DI BENEDETTO, LOT (DPT)
Entity Type:Individual
Prefix:
First Name:LOT
Middle Name:
Last Name:DI BENEDETTO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 7TH ST
Mailing Address - Street 2:STE C
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4952
Mailing Address - Country:US
Mailing Address - Phone:469-693-2568
Mailing Address - Fax:
Practice Address - Street 1:1607 7TH ST
Practice Address - Street 2:STE C
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4952
Practice Address - Country:US
Practice Address - Phone:505-454-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1220967225100000X
CA36565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46956204Medicaid