Provider Demographics
NPI:1699923110
Name:BENNETT CHIROPRACTIC CLINIC, LLC
Entity type:Organization
Organization Name:BENNETT CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER OF BUSINESS
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF CHIROPRACT
Authorized Official - Phone:864-984-6731
Mailing Address - Street 1:501 S HARPER ST
Mailing Address - Street 2:P O BOX 218
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2802
Mailing Address - Country:US
Mailing Address - Phone:864-984-6731
Mailing Address - Fax:864-983-1278
Practice Address - Street 1:501 S HARPER ST
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2802
Practice Address - Country:US
Practice Address - Phone:864-984-6731
Practice Address - Fax:864-983-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2070Medicaid
SCU63152Medicare UPIN
SCCH2070Medicaid
SCU631529133Medicare PIN