Provider Demographics
NPI:1871048843
Name:ANDERSON, BEN (ATC)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W 7TH ST
Mailing Address - Street 2:#1802
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-1051
Mailing Address - Country:US
Mailing Address - Phone:918-508-1175
Mailing Address - Fax:918-631-3057
Practice Address - Street 1:800 S TUCKER DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-9700
Practice Address - Country:US
Practice Address - Phone:918-631-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer