Provider Demographics
NPI:1669937090
Name:BALL, BENNY (LMT)
Entity type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:BALL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 DELACY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-1903
Mailing Address - Country:US
Mailing Address - Phone:904-437-1347
Mailing Address - Fax:
Practice Address - Street 1:2 INDEPENDENT DR STE 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-5016
Practice Address - Country:US
Practice Address - Phone:904-437-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL57604225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist