Provider Demographics
NPI:1376875179
Name:BENNETT, ZACHARY MARK (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:MARK
Last Name:BENNETT
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11250 W ROSE LAKE ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5885
Mailing Address - Country:US
Mailing Address - Phone:208-936-0333
Mailing Address - Fax:
Practice Address - Street 1:50 S BROADWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7283
Practice Address - Country:US
Practice Address - Phone:208-377-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-1106237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist