Provider Demographics
NPI:1508062225
Name:CLINTON A BENNION DC, PLC
Entity Type:Organization
Organization Name:CLINTON A BENNION DC, PLC
Other - Org Name:FIESTA CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNION
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-649-5297
Mailing Address - Street 1:1303 S LONGMORE STE 8
Mailing Address - Street 2:
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:480-649-1790
Practice Address - Street 1:1303 S LONGMORE STE 8
Practice Address - Street 2:
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:480-649-1790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty