Provider Demographics
NPI:1215989603
Name:BENNETT, LOREN WALLACE (OD, MPH)
Entity type:Individual
Prefix:DR
First Name:LOREN
Middle Name:WALLACE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:OD, MPH
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4000
Mailing Address - Street 2:EYE CLINIC 112E
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-4000
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:423-979-3530
Practice Address - Street 1:JAMES H. QUILLEN VAMC, SIDNEY/LAMONT ST
Practice Address - Street 2:EYE CLINIC 112E
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:423-979-3530
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN1409152W00000X
OH4003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist