Provider Demographics
NPI:1205052578
Name:JOE M. BENNETT, D.O., & ASSOCIATES, P.C.
Entity type:Organization
Organization Name:JOE M. BENNETT, D.O., & ASSOCIATES, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-826-6633
Mailing Address - Street 1:1708 S LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7542
Mailing Address - Country:US
Mailing Address - Phone:660-826-6633
Mailing Address - Fax:660-826-6440
Practice Address - Street 1:1706 S LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7542
Practice Address - Country:US
Practice Address - Phone:660-826-4729
Practice Address - Fax:660-826-6440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12333671332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0235730001Medicare NSC
MOC49960Medicare UPIN