Provider Demographics
NPI:1235307232
Name:BENNETT, ALAN CHARLES (MA)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:CHARLES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11526
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-1526
Mailing Address - Country:US
Mailing Address - Phone:714-567-7635
Mailing Address - Fax:714-834-7182
Practice Address - Street 1:1300 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4434
Practice Address - Country:US
Practice Address - Phone:714-567-7635
Practice Address - Fax:714-834-7182
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17OtherOTHER SERVICES PROVIDER