Healthcare Provider Details

I. General information

NPI: 1083946586
Provider Name (Legal Business Name): BENNETT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 WILLOW CREEK RD
PRESCOTT AZ
86301-1428
US

IV. Provider business mailing address

1202 WILLOW CREEK RD
PRESCOTT AZ
86301-1428
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-9400
  • Fax: 928-771-9464
Mailing address:
  • Phone: 928-771-9400
  • Fax: 928-771-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number5009
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 6078
License Number StateAZ

VIII. Authorized Official

Name: DR. WAYNE ANTHONY BENNETT
Title or Position: DIRECTOR
Credential: D.C.
Phone: 928-771-9400