Provider Demographics
NPI:1639615578
Name:PAGE, BENNETT ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:BENNETT
Middle Name:ALEXANDER
Last Name:PAGE
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 1:1005 N BEECH DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-9422
Mailing Address - Country:US
Mailing Address - Phone:931-703-3411
Mailing Address - Fax:
Practice Address - Street 1:1005 N BEECH DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-9422
Practice Address - Country:US
Practice Address - Phone:931-703-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer