Provider Demographics
NPI:1821969635
Name:COLBERT, BENNIE
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:
Last Name:COLBERT
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 1:966 COPPET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4717
Mailing Address - Country:US
Mailing Address - Phone:907-460-6851
Mailing Address - Fax:
Practice Address - Street 1:966 COPPET ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4717
Practice Address - Country:US
Practice Address - Phone:907-460-6851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility