Provider Demographics
NPI:1205547908
Name:BENTON, CALEB R
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:R
Last Name:BENTON
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 1:4046 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-1692
Mailing Address - Country:US
Mailing Address - Phone:252-214-3356
Mailing Address - Fax:
Practice Address - Street 1:4046 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1692
Practice Address - Country:US
Practice Address - Phone:252-214-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37670725172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver