Provider Demographics
NPI:1285282178
Name:BERISTAIN, BENJAIN A
Entity type:Individual
Prefix:
First Name:BENJAIN
Middle Name:A
Last Name:BERISTAIN
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 1:5217 W CORNELIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3305
Mailing Address - Country:US
Mailing Address - Phone:773-908-3219
Mailing Address - Fax:
Practice Address - Street 1:3015 HAROLDS CRES
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2009
Practice Address - Country:US
Practice Address - Phone:708-420-6057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.481623163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse