Provider Demographics
NPI:1437452745
Name:BENNETT, BROCK (DC)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
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 1:447 N 300 W
Mailing Address - Street 2:SUITE #5
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-4203
Mailing Address - Country:US
Mailing Address - Phone:801-544-2355
Mailing Address - Fax:801-544-2358
Practice Address - Street 1:447 N 300 W
Practice Address - Street 2:SUITE #5
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-4203
Practice Address - Country:US
Practice Address - Phone:801-544-2355
Practice Address - Fax:801-544-2358
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5493087-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician