Healthcare Provider Details

I. General information

NPI: 1952386542
Provider Name (Legal Business Name): WAYNE A BENNETT D.C.,D.A.B.C.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/04/2011
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 Number5009
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: