Provider Demographics
NPI:1245259738
Name:BENSON, JOHN ANDREW (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:BENSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 CLOQUET AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1675
Mailing Address - Country:US
Mailing Address - Phone:218-879-6049
Mailing Address - Fax:
Practice Address - Street 1:807 CLOQUET AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1675
Practice Address - Country:US
Practice Address - Phone:218-879-6049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2484111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN671028000Medicaid
MN350003325Medicare ID - Type Unspecified
MN671028000Medicaid