Provider Demographics
NPI:1063977577
Name:ENDEL, BENJAMIN RYAN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RYAN
Last Name:ENDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:RYAN
Other - Last Name:ENDEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2825 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2997
Mailing Address - Country:US
Mailing Address - Phone:870-312-8478
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPTA-A03885225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant