Provider Demographics
NPI:1952386542
Name:BENNETT, WAYNE A (DC,DABCO)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC,DABCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1400
Mailing Address - Country:US
Mailing Address - Phone:928-771-9400
Mailing Address - Fax:928-771-9464
Practice Address - Street 1:1202 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1400
Practice Address - Country:US
Practice Address - Phone:928-771-9400
Practice Address - Fax:928-771-9464
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5009111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU34258Medicare UPIN
AZZ103169Medicare ID - Type Unspecified