Provider Demographics
NPI:1710525092
Name:BENNETT, REX ROSS JR
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:ROSS
Last Name:BENNETT
Suffix:JR
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 1:22687 E CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-5357
Mailing Address - Country:US
Mailing Address - Phone:831-596-8866
Mailing Address - Fax:
Practice Address - Street 1:22687 E CLIFF DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-5357
Practice Address - Country:US
Practice Address - Phone:831-596-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service