Provider Demographics
NPI:1174638084
Name:BENNETCH, TOM D (PT)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:D
Last Name:BENNETCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 MCCULLOCH BLVD N
Mailing Address - Street 2:#D282
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5749
Mailing Address - Country:US
Mailing Address - Phone:928-453-0501
Mailing Address - Fax:
Practice Address - Street 1:297 S LAKE HAVASU AVE
Practice Address - Street 2:#102
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-453-0501
Practice Address - Fax:928-453-0502
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109060Medicare ID - Type Unspecified