Provider Demographics
NPI:1649636705
Name:HURSTON, BENJMAIN W (DPT)
Entity type:Individual
Prefix:MR
First Name:BENJMAIN
Middle Name:W
Last Name:HURSTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 TECHNACENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6028
Mailing Address - Country:US
Mailing Address - Phone:334-625-5795
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:7061 HALCYON SUMMIT DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6927
Practice Address - Country:US
Practice Address - Phone:334-396-2110
Practice Address - Fax:334-396-2115
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK13774482OtherCAQH
AL511-73438OtherBCBS OF AL
AL511-73432OtherBCBS OF AL
AL511-73434OtherBCBS OF AL
AL511-73440OtherBCBS OF AL
AL511-73440OtherBCBS OF AL