Provider Demographics
NPI:1811129745
Name:BENTON FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:BENTON FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-965-1000
Mailing Address - Street 1:188 BURT BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4900
Mailing Address - Country:US
Mailing Address - Phone:318-965-1000
Mailing Address - Fax:
Practice Address - Street 1:188 BURT BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-4900
Practice Address - Country:US
Practice Address - Phone:318-965-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04759363LF0000X
LAMD09509R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty