Provider Demographics
NPI:1902316854
Name:SMITH, BEN (LMT, CPT, CKTP)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT, CPT, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 W FIREWEED LN STE 201
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-1754
Mailing Address - Country:US
Mailing Address - Phone:907-290-0668
Mailing Address - Fax:907-202-9176
Practice Address - Street 1:1113 W FIREWEED LN STE 201
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-1754
Practice Address - Country:US
Practice Address - Phone:907-290-0668
Practice Address - Fax:907-202-9176
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist