Provider Demographics
NPI:1215330279
Name:SWAFFORD, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:SWAFFORD
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 1:1691 CURTIS VICKERS RD
Mailing Address - Street 2:
Mailing Address - City:AMBROSE
Mailing Address - State:GA
Mailing Address - Zip Code:31512-3022
Mailing Address - Country:US
Mailing Address - Phone:912-592-6435
Mailing Address - Fax:912-720-1009
Practice Address - Street 1:159 TROJAN WAY
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-8263
Practice Address - Country:US
Practice Address - Phone:912-393-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0006332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer