Provider Demographics
NPI:1295455848
Name:ELCHONEN, BEN
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:ELCHONEN
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 1:25911 STRATFORD PL
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1027
Mailing Address - Country:US
Mailing Address - Phone:646-504-4236
Mailing Address - Fax:
Practice Address - Street 1:25911 STRATFORD PL
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1027
Practice Address - Country:US
Practice Address - Phone:646-504-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9884723374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9884723Medicaid