Provider Demographics
NPI:1316236995
Name:BENNETT CLINIC LLC
Entity type:Organization
Organization Name:BENNETT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-772-7200
Mailing Address - Street 1:7876 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2216
Mailing Address - Country:US
Mailing Address - Phone:928-772-7200
Mailing Address - Fax:928-772-7779
Practice Address - Street 1:7876 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2216
Practice Address - Country:US
Practice Address - Phone:928-772-7200
Practice Address - Fax:928-772-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20636829-L332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ139537OtherMEDICARE PTAN