Provider Demographics
NPI:1124894852
Name:AMMONS, BENJAMIN KLAUS
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KLAUS
Last Name:AMMONS
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 1:5003 HIGHWAY 282
Mailing Address - Street 2:
Mailing Address - City:RUDY
Mailing Address - State:AR
Mailing Address - Zip Code:72952-9016
Mailing Address - Country:US
Mailing Address - Phone:479-231-6145
Mailing Address - Fax:
Practice Address - Street 1:2801 OLD GREENWOOD RD STE 14
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4560
Practice Address - Country:US
Practice Address - Phone:479-222-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
AROTA971224Z00000X
AROT-A971224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant