Provider Demographics
NPI:1982283115
Name:PUPO, BENJAMIN EUGENE (DC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EUGENE
Last Name:PUPO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E SHERMAN AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2761
Mailing Address - Country:US
Mailing Address - Phone:208-751-8820
Mailing Address - Fax:
Practice Address - Street 1:410 E SHERMAN AVE STE 209
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2761
Practice Address - Country:US
Practice Address - Phone:509-993-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6842111NN0400X
ID8961561111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology