Provider Demographics
NPI:1972335164
Name:PAGE, BENJAMIN KYLE
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KYLE
Last Name:PAGE
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 1:1202 SAUNDERS RD
Mailing Address - Street 2:
Mailing Address - City:PORTAL
Mailing Address - State:GA
Mailing Address - Zip Code:30450-4521
Mailing Address - Country:US
Mailing Address - Phone:706-818-5308
Mailing Address - Fax:
Practice Address - Street 1:1202 SAUNDERS RD
Practice Address - Street 2:
Practice Address - City:PORTAL
Practice Address - State:GA
Practice Address - Zip Code:30450-4521
Practice Address - Country:US
Practice Address - Phone:706-818-5308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer