Provider Demographics
NPI:1912084591
Name:BENNETT, LARRY D
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 W HENDERSON AVE # 338
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1454
Mailing Address - Country:US
Mailing Address - Phone:559-784-9355
Mailing Address - Fax:559-784-9359
Practice Address - Street 1:130 N VILLA ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3218
Practice Address - Country:US
Practice Address - Phone:559-784-9355
Practice Address - Fax:559-784-9359
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0291190111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0291190Medicaid
CADC0291190Medicaid