Provider Demographics
NPI:1427234947
Name:BENNETT, KENNETH CHARLES
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHARLES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMF
Mailing Address - Street 1:68 MICHIGAN AVE E
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-4011
Mailing Address - Country:US
Mailing Address - Phone:269-962-8729
Mailing Address - Fax:269-962-9924
Practice Address - Street 1:68 MICHIGAN AVE E
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-4011
Practice Address - Country:US
Practice Address - Phone:269-962-8729
Practice Address - Fax:269-962-9924
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1129360001Medicare NSC