Provider Demographics
NPI:1497780951
Name:BENNETT, MICHAEL L (D C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429
Mailing Address - Country:US
Mailing Address - Phone:352-563-6471
Mailing Address - Fax:352-863-5062
Practice Address - Street 1:375 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429
Practice Address - Country:US
Practice Address - Phone:352-563-6471
Practice Address - Fax:352-863-5062
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH00005987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22976OtherBLUE CROSS
FL22976OtherBLUE CROSS
U48421Medicare UPIN