Provider Demographics
NPI:1821504143
Name:BENNETT, CHARLES ARCHIE JR (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ARCHIE
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1423
Mailing Address - Country:US
Mailing Address - Phone:540-459-5335
Mailing Address - Fax:540-459-5339
Practice Address - Street 1:158 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1423
Practice Address - Country:US
Practice Address - Phone:540-459-5335
Practice Address - Fax:540-459-5339
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02619237700000X
VA2101000640237700000X
WV583237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist