Provider Demographics
NPI:1770886426
Name:BENNETT CLINIC, PC
Entity type:Organization
Organization Name:BENNETT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:B
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:580-625-2273
Mailing Address - Street 1:PO BOX 964
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OK
Mailing Address - Zip Code:73932-0964
Mailing Address - Country:US
Mailing Address - Phone:580-625-2273
Mailing Address - Fax:580-625-2274
Practice Address - Street 1:623 AVENUE C
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OK
Practice Address - Zip Code:73932-3126
Practice Address - Country:US
Practice Address - Phone:580-625-2273
Practice Address - Fax:580-625-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0071654261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200317900AMedicaid