Provider Demographics
NPI:1700947942
Name:BENNETT, BRENT LEROY (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LEROY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5223 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2503
Mailing Address - Country:US
Mailing Address - Phone:614-322-9339
Mailing Address - Fax:614-322-9345
Practice Address - Street 1:5223 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2503
Practice Address - Country:US
Practice Address - Phone:614-322-9339
Practice Address - Fax:614-322-9345
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1172111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor