Provider Demographics
NPI:1326486184
Name:DR WALTER C BENNETT
Entity type:Organization
Organization Name:DR WALTER C BENNETT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, NP-C
Authorized Official - Phone:931-251-3009
Mailing Address - Street 1:2310 THORNTON TAYLOR PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3668
Mailing Address - Country:US
Mailing Address - Phone:931-251-3009
Mailing Address - Fax:931-251-3008
Practice Address - Street 1:4140 THORNTON TAYLOR PKWY STE D
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2290
Practice Address - Country:US
Practice Address - Phone:931-251-3009
Practice Address - Fax:931-251-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16762363LF0000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty