Provider Demographics
NPI:1609827005
Name:BENNETT, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 BELL RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2112
Mailing Address - Country:US
Mailing Address - Phone:615-731-0549
Mailing Address - Fax:
Practice Address - Street 1:777 BELL RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2112
Practice Address - Country:US
Practice Address - Phone:615-731-0549
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1435111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3970441Medicare ID - Type Unspecified
TNU76344Medicare UPIN