Provider Demographics
NPI:1780657411
Name:BENNETT, JOHN H (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:H
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 1:1986 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5001
Mailing Address - Country:US
Mailing Address - Phone:941-497-4222
Mailing Address - Fax:941-497-1495
Practice Address - Street 1:1986 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5001
Practice Address - Country:US
Practice Address - Phone:941-497-4222
Practice Address - Fax:941-497-1495
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050692300Medicaid
FLT84528Medicare UPIN
FL70800Medicare ID - Type Unspecified