Healthcare Provider Details

I. General information

NPI: 1871955435
Provider Name (Legal Business Name): MARK RICHARD BENNETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

IV. Provider business mailing address

709 W MAIN ST
MANCHESTER IA
52057-1526
US

V. Phone/Fax

Practice location:
  • Phone: 563-822-1435
  • Fax: 563-822-1436
Mailing address:
  • Phone: 563-822-1435
  • Fax: 563-822-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD131948
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: