Healthcare Provider Details

I. General information

NPI: 1508841107
Provider Name (Legal Business Name): WAYNE A BENNETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 WILLOW CREEK RD
PRESCOTT AZ
86301-1400
US

IV. Provider business mailing address

1202 WILLOW CREEK RD
PRESCOTT AZ
86301-1400
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 TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. WAYNE BENNETT
Title or Position: OWNER
Credential: D.C.,D.A.B.C.O.
Phone: 928-771-9400