Provider Demographics
NPI:1356734651
Name:JOHNSON, BENJAMIN EDWARD MICHAEL (ATC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD MICHAEL
Last Name:JOHNSON
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 1:2751 2ND AVE N STOP 9013
Mailing Address - Street 2:HYSLOP SPORTS CENTER ROOM 144
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-9013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2751 2ND AVE N STOP 9013
Practice Address - Street 2:HYSLOP SPORTS CENTER ROOM 144
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-9013
Practice Address - Country:US
Practice Address - Phone:701-777-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND517-132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer