Provider Demographics
NPI:1750639340
Name:BENTLEY, CARMEN L
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:L
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LANTON RD. #4
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-4759
Mailing Address - Country:US
Mailing Address - Phone:417-274-3715
Mailing Address - Fax:
Practice Address - Street 1:1111 LANTON RD. #4
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-4759
Practice Address - Country:US
Practice Address - Phone:417-274-3715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor