Provider Demographics
NPI:1457755266
Name:BENNEBEL LLC
Entity Type:Organization
Organization Name:BENNEBEL LLC
Other - Org Name:MIRACLE EAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-957-6418
Mailing Address - Street 1:1059 E IRON EAGLE DR
Mailing Address - Street 2:SUITE 175
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6855
Mailing Address - Country:US
Mailing Address - Phone:208-957-6418
Mailing Address - Fax:
Practice Address - Street 1:1059 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6855
Practice Address - Country:US
Practice Address - Phone:208-957-6418
Practice Address - Fax:360-573-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1106237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty