Provider Demographics
NPI:1447925664
Name:GLOVER, BENITA Y
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:Y
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 W INDEPENDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6550
Mailing Address - Country:US
Mailing Address - Phone:678-724-6454
Mailing Address - Fax:
Practice Address - Street 1:80 W INDEPENDENCE CIR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6550
Practice Address - Country:US
Practice Address - Phone:678-724-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058988264172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver