Provider Demographics
NPI:1164691267
Name:BENNETT, GRANT DOUGLAS
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:DOUGLAS
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 1:6223 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4043
Mailing Address - Country:US
Mailing Address - Phone:912-807-6625
Mailing Address - Fax:912-807-0212
Practice Address - Street 1:3351 US HIGHWAY 84
Practice Address - Street 2:SUITE 102
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-2100
Practice Address - Country:US
Practice Address - Phone:912-807-6625
Practice Address - Fax:912-807-0212
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2008500332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies