Provider Demographics
NPI:1356452254
Name:BENNETT, CARL HENRY (DC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:HENRY
Last Name:BENNETT
Suffix:
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 1:3945 SOUTH NOVA ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-767-1100
Mailing Address - Fax:386-767-1103
Practice Address - Street 1:3945 SOUTH NOVA ROAD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127
Practice Address - Country:US
Practice Address - Phone:386-767-1100
Practice Address - Fax:386-767-1103
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T84514Medicare UPIN
70735AMedicare ID - Type Unspecified