Provider Demographics
NPI:1932585841
Name:BENTON MEDICAL
Entity Type:Organization
Organization Name:BENTON MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAKOTA
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-375-4097
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:318-375-4004
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:318-965-5017
Practice Address - Fax:318-965-5019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH CADDO HOSPITAL SERVICE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2508784Medicaid