Provider Demographics
NPI:1235185117
Name:BENNETT, JOSEPH STEPHEN JR (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:STEPHEN
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 MUNDY MILL PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-2530
Mailing Address - Country:US
Mailing Address - Phone:770-534-8614
Mailing Address - Fax:770-534-8169
Practice Address - Street 1:4211 MUNDY MILL PL
Practice Address - Street 2:SUITE B
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2530
Practice Address - Country:US
Practice Address - Phone:770-534-8614
Practice Address - Fax:770-534-8169
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT97471Medicare UPIN