Provider Demographics
NPI:1215268503
Name:BENNETT CHIROPRACTIC
Entity type:Organization
Organization Name:BENNETT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-546-3600
Mailing Address - Street 1:195 E GENTILE ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3754
Mailing Address - Country:US
Mailing Address - Phone:801-546-3600
Mailing Address - Fax:801-546-0966
Practice Address - Street 1:195 E GENTILE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-3754
Practice Address - Country:US
Practice Address - Phone:801-546-3600
Practice Address - Fax:801-546-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT165905-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000005763OtherMEDICARE ID - TYPE UNSPECIFIED
UT=========003Medicaid
UTT78070Medicare UPIN