Provider Demographics
NPI:1255930962
Name:FODDRILL, BENJAMIN (ATC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FODDRILL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7380 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9309
Mailing Address - Country:US
Mailing Address - Phone:517-420-6433
Mailing Address - Fax:
Practice Address - Street 1:7380 CLEARVIEW DR
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9309
Practice Address - Country:US
Practice Address - Phone:517-420-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010025182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer