Provider Demographics
NPI:1982636627
Name:BENNETT, BRIAN LEE (DC,DAAPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC,DAAPM
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:LEE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC,DAAPM
Mailing Address - Street 1:5445 DETROIT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44054
Mailing Address - Country:US
Mailing Address - Phone:440-240-9111
Mailing Address - Fax:440-934-5459
Practice Address - Street 1:5445 DETROIT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44054
Practice Address - Country:US
Practice Address - Phone:440-240-9111
Practice Address - Fax:440-934-5459
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2954111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2290051Medicaid
OH000000324155OtherBCBS
OH000000324155OtherBCBS
OHU90521Medicare UPIN