Provider Demographics
NPI:1982712626
Name:BARNES, BENJAMIN DONELL
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DONELL
Last Name:BARNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:9484 W. LAKE MEAD BLVD
Practice Address - Street 2:STE. 8-10
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8339
Practice Address - Country:US
Practice Address - Phone:702-243-7744
Practice Address - Fax:702-243-9688
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NV2261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1149363OtherLICENSE #