Provider Demographics
NPI:1780715854
Name:BENFORD, CHARLES A SR (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:BENFORD
Suffix:SR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5888 RIDGEWOOD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2644
Mailing Address - Country:US
Mailing Address - Phone:601-978-1798
Mailing Address - Fax:601-978-1799
Practice Address - Street 1:5888 RIDGEWOOD RD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2644
Practice Address - Country:US
Practice Address - Phone:601-978-1798
Practice Address - Fax:601-978-1799
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05855578Medicaid
MS640830003OtherTAX ID
MS640830003OtherTAX ID