Provider Demographics
NPI:1457411290
Name:BENNETT, TINA MALLARD (DC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MALLARD
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4910
Mailing Address - Country:US
Mailing Address - Phone:386-767-1100
Mailing Address - Fax:386-767-1102
Practice Address - Street 1:3945 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4910
Practice Address - Country:US
Practice Address - Phone:386-767-1100
Practice Address - Fax:386-767-1102
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor