Provider Demographics
NPI:1316049281
Name:HEVERLY, BENJAMIN A B
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:A B
Last Name:HEVERLY
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 1:5722 INTEGRITY DR
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38054-5028
Mailing Address - Country:US
Mailing Address - Phone:901-874-6264
Mailing Address - Fax:
Practice Address - Street 1:5722 INTEGRITY DR
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38054-5028
Practice Address - Country:US
Practice Address - Phone:901-874-6264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman