Provider Demographics
NPI:1407872930
Name:BENNION, CLINT (DC)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:BENNION
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 1:1303 S LONGMORE
Mailing Address - Street 2:SUITE #8
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9607
Mailing Address - Country:US
Mailing Address - Phone:480-649-5297
Mailing Address - Fax:480-539-4685
Practice Address - Street 1:1303 S LONGMORE
Practice Address - Street 2:SUITE #8
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-9607
Practice Address - Country:US
Practice Address - Phone:480-649-5297
Practice Address - Fax:480-539-4685
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU95510Medicare UPIN
AZZ75108Medicare ID - Type Unspecified