Provider Demographics
NPI:1376700401
Name:GRANT D. BENNETT
Entity Type:Organization
Organization Name:GRANT D. BENNETT
Other - Org Name:BENNETT MOBILITY PRODUCTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MANAGER/TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-614-2269
Mailing Address - Street 1:6223 CLARK RD.
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516
Mailing Address - Country:US
Mailing Address - Phone:912-807-6625
Mailing Address - Fax:912-807-0212
Practice Address - Street 1:6223 CLARK RD.
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516
Practice Address - Country:US
Practice Address - Phone:912-807-6625
Practice Address - Fax:912-807-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108583AMedicaid
GA879144878AMedicaid
GA879144878AMedicaid
GA6525670001Medicare NSC