Provider Demographics
NPI:1689015612
Name:BENAVIDEZ, MICHAEL DAVID (LMT, MMP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BENAVIDEZ
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 LANDAU LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7301
Mailing Address - Country:US
Mailing Address - Phone:817-602-7922
Mailing Address - Fax:
Practice Address - Street 1:1204 LANDAU LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7301
Practice Address - Country:US
Practice Address - Phone:817-602-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2013-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS.8495R225700000X
TXMT109593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist