Provider Demographics
NPI:1861848491
Name:PACK, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PACK
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 1:415 W MARBLE ST
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4330
Mailing Address - Country:US
Mailing Address - Phone:832-961-0705
Mailing Address - Fax:
Practice Address - Street 1:415 W MARBLE ST
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4330
Practice Address - Country:US
Practice Address - Phone:832-961-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX826409163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse