Provider Demographics
NPI:1710620604
Name:BENAVIDEZ, NICHOLAS COLE
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:COLE
Last Name:BENAVIDEZ
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 1:1162 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-3650
Mailing Address - Country:US
Mailing Address - Phone:937-423-3903
Mailing Address - Fax:
Practice Address - Street 1:1162 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3650
Practice Address - Country:US
Practice Address - Phone:937-423-3903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide