Provider Demographics
NPI:1730721655
Name:STOVALL, BENJAMIN CLARK (PT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CLARK
Last Name:STOVALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 MEADOW WOOD RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4473
Mailing Address - Country:US
Mailing Address - Phone:912-281-2619
Mailing Address - Fax:
Practice Address - Street 1:2003 ALICE ST STE A
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6209
Practice Address - Country:US
Practice Address - Phone:912-285-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist