Provider Demographics
NPI:1316326143
Name:BENNETT, MICAH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 ROUTE 44
Mailing Address - Street 2:BUILDING #2
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-7811
Mailing Address - Country:US
Mailing Address - Phone:845-518-4827
Mailing Address - Fax:845-691-6081
Practice Address - Street 1:1372 ROUTE 44
Practice Address - Street 2:BUILDING #2
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7811
Practice Address - Country:US
Practice Address - Phone:845-518-4827
Practice Address - Fax:845-691-6081
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY992089481172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver