Provider Demographics
NPI:1174845168
Name:BENNETT, CAROLIN DORIS (LAC)
Entity Type:Individual
Prefix:
First Name:CAROLIN
Middle Name:DORIS
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5012
Mailing Address - Country:US
Mailing Address - Phone:310-826-3706
Mailing Address - Fax:310-826-3713
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-826-3706
Practice Address - Fax:310-826-3713
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12843171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist