Provider Demographics
NPI:1528450814
Name:SUKUT, BEN
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:SUKUT
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 1:304 1/2 LEVASSEUR ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 KENSINGTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5674
Practice Address - Country:US
Practice Address - Phone:406-549-9244
Practice Address - Fax:406-549-7260
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC 7811225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist