Provider Demographics
NPI:1508841107
Name:WAYNE A BENNETT
Entity Type:Organization
Organization Name:WAYNE A BENNETT
Other - Org Name:BENNETT CHIROPRACITC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC,DABCO
Authorized Official - Phone:928-771-9400
Mailing Address - Street 1:1202 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1400
Mailing Address - Country:US
Mailing Address - Phone:928-771-9400
Mailing Address - Fax:928-771-9464
Practice Address - Street 1:1202 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1400
Practice Address - Country:US
Practice Address - Phone:928-771-9400
Practice Address - Fax:928-771-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ103168Medicare ID - Type Unspecified