Provider Demographics
NPI:1194994301
Name:STEPHEN BENCHO
Entity type:Organization
Organization Name:STEPHEN BENCHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENCHO
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:865-475-2657
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-0327
Mailing Address - Country:US
Mailing Address - Phone:865-475-2657
Mailing Address - Fax:865-475-2657
Practice Address - Street 1:124 W OLD ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-1945
Practice Address - Country:US
Practice Address - Phone:865-475-2657
Practice Address - Fax:865-475-2657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0656630001OtherPTAN
TN3518221Medicaid
TN3518221Medicaid
TN0656630001Medicare NSC
TN0656630001OtherPTAN