Provider Demographics
NPI:1952439309
Name:BENTON, REGENIA GAIL (LAC)
Entity Type:Individual
Prefix:
First Name:REGENIA
Middle Name:GAIL
Last Name:BENTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 SE DIVISION ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1099
Mailing Address - Country:US
Mailing Address - Phone:503-975-9798
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST
Practice Address - Street 2:SUITE 115
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:503-975-9798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00674171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist