Provider Demographics
NPI:1902311939
Name:WEAVER, BENJAMIN R
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:R
Last Name:WEAVER
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 1:10677 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2062
Mailing Address - Country:US
Mailing Address - Phone:770-741-0712
Mailing Address - Fax:
Practice Address - Street 1:10677 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2062
Practice Address - Country:US
Practice Address - Phone:770-741-0712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies