Provider Demographics
NPI:1215962311
Name:BENNETT, TRUDY L (DC)
Entity type:Individual
Prefix:DR
First Name:TRUDY
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S RODNEY PARHAM RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4774
Mailing Address - Country:US
Mailing Address - Phone:501-663-4663
Mailing Address - Fax:501-663-7689
Practice Address - Street 1:300 S RODNEY PARHAM RD
Practice Address - Street 2:SUITE 11
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4774
Practice Address - Country:US
Practice Address - Phone:501-663-4663
Practice Address - Fax:501-663-7689
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1435111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136565718Medicaid
AR5T449OtherBCBS PROVIDER ID#
AR7483095OtherAETNA
AR19689000000OtherQUAL CHOICE
AR5C748OtherBCBS GROUP ID#
ARP00613713OtherRR MEDICARE-PALMETTO
ARU64454Medicare UPIN
AR5T449Medicare ID - Type UnspecifiedPROVIDER ID#