Provider Demographics
NPI:1720605397
Name:BENNETT, BRUCE ADAM (RN)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ADAM
Last Name:BENNETT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29614 461ST AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:SD
Mailing Address - Zip Code:57014-6711
Mailing Address - Country:US
Mailing Address - Phone:605-408-6452
Mailing Address - Fax:
Practice Address - Street 1:610 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-2040
Practice Address - Country:US
Practice Address - Phone:605-563-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR024679163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool