Provider Demographics
NPI:1083946586
Name:BENNETT CLINIC LLC
Entity Type:Organization
Organization Name:BENNETT CLINIC LLC
Other - Org Name:BENNETT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-771-9400
Mailing Address - Street 1:1202 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1428
Mailing Address - Country:US
Mailing Address - Phone:928-771-9400
Mailing Address - Fax:928-771-9464
Practice Address - Street 1:1202 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1428
Practice Address - Country:US
Practice Address - Phone:928-771-9400
Practice Address - Fax:928-771-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5009111NX0800X
AZPT 6078261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty