Provider Demographics
NPI:1821774464
Name:BENNETT, BRIAN
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BENNETT
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 1:1690 IOWA DR
Mailing Address - Street 2:
Mailing Address - City:LE CLAIRE
Mailing Address - State:IA
Mailing Address - Zip Code:52753-9231
Mailing Address - Country:US
Mailing Address - Phone:563-676-3156
Mailing Address - Fax:
Practice Address - Street 1:322 N CODY RD
Practice Address - Street 2:
Practice Address - City:LE CLAIRE
Practice Address - State:IA
Practice Address - Zip Code:52753-9220
Practice Address - Country:US
Practice Address - Phone:563-635-6057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121214111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor