Provider Demographics
NPI:1518168053
Name:SARITA L BENNETT
Entity Type:Organization
Organization Name:SARITA L BENNETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-799-0011
Mailing Address - Street 1:RT 2 BOX 386
Mailing Address - Street 2:
Mailing Address - City:MARLINTON
Mailing Address - State:WV
Mailing Address - Zip Code:24954-9743
Mailing Address - Country:US
Mailing Address - Phone:304-799-0011
Mailing Address - Fax:304-799-0035
Practice Address - Street 1:RT 2 BOX 386
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954-9743
Practice Address - Country:US
Practice Address - Phone:304-799-0011
Practice Address - Fax:304-799-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1755207Q00000X, 208D00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4902001000Medicaid
WV5600573000Medicaid
WV4902001000Medicaid
WVSASP01741Medicare PIN
SP01741Medicare PIN