MEDICARE: DR. BRENT LEROY BENNETT D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1172	OH

General Provider Information

NPI Number	:	1700947942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT LEROY BENNETT D.C.

Provider Business Mailing Address
First Line	:	5223 E. MAIN ST.
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-2503
Country	:	US
Telephone Number	:	614-322-9339
Fax Number	:	614-322-9345

Provider Business Practice Location Address
First Line	:	5223 E. MAIN ST.
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-2503
Country	:	US
Telephone Number	:	614-322-9339
Fax Number	:	614-322-9345

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/08/2007

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