Provider Demographics
NPI:1356758494
Name:WONDERFULLY MADE PEDIATRICS
Entity type:Organization
Organization Name:WONDERFULLY MADE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-440-6240
Mailing Address - Street 1:1215 DORNEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6879
Mailing Address - Country:US
Mailing Address - Phone:314-440-6240
Mailing Address - Fax:
Practice Address - Street 1:1215 DORNEWOOD PL
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-6879
Practice Address - Country:US
Practice Address - Phone:314-440-6240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003006580252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency