Provider Demographics
NPI:1942428057
Name:J. STEPHEN BENNETT JR.
Entity Type:Organization
Organization Name:J. STEPHEN BENNETT JR.
Other - Org Name:NORTHEAST GA CHIROPRACTIC CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:770-534-8614
Mailing Address - Street 1:4211 MUNDY MILL PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-2540
Mailing Address - Country:US
Mailing Address - Phone:770-534-8614
Mailing Address - Fax:770-534-8169
Practice Address - Street 1:4211 MUNDY MILL PL
Practice Address - Street 2:SUITE B
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2540
Practice Address - Country:US
Practice Address - Phone:770-534-8614
Practice Address - Fax:770-534-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty