Provider Demographics
NPI:1295269074
Name:CHERYL L. BENNETT OD, PLLC
Entity type:Organization
Organization Name:CHERYL L. BENNETT OD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-472-7703
Mailing Address - Street 1:28 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1740
Mailing Address - Country:US
Mailing Address - Phone:304-472-7703
Mailing Address - Fax:304-472-8088
Practice Address - Street 1:100 BUCKHANNON
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-8422
Practice Address - Country:US
Practice Address - Phone:304-472-7703
Practice Address - Fax:304-472-8088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV984-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81613Medicare UPIN