Provider Demographics
NPI:1548234115
Name:BENNETT, BLAKE W (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:W
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 1:1727 T P WHITE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-2861
Mailing Address - Country:US
Mailing Address - Phone:501-985-7711
Mailing Address - Fax:501-985-8385
Practice Address - Street 1:1727 T P WHITE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-2861
Practice Address - Country:US
Practice Address - Phone:501-985-7711
Practice Address - Fax:501-985-8385
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1412111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T401Medicare ID - Type Unspecified
ARU63233Medicare UPIN