Provider Demographics
NPI:1841887114
Name:MISEK, BENJAMIN (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MISEK
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PINEBROOK BLVD APT C3
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-8279
Mailing Address - Country:US
Mailing Address - Phone:860-299-5477
Mailing Address - Fax:
Practice Address - Street 1:1600 PINEBROOK BLVD APT C3
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-8279
Practice Address - Country:US
Practice Address - Phone:860-299-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9783091-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist