Provider Demographics
NPI:1538592860
Name:STOVER, BENEDICT JOHN (PTA)
Entity type:Individual
Prefix:
First Name:BENEDICT
Middle Name:JOHN
Last Name:STOVER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-8781
Mailing Address - Country:US
Mailing Address - Phone:518-269-5623
Mailing Address - Fax:
Practice Address - Street 1:901 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4511
Practice Address - Country:US
Practice Address - Phone:336-599-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant