Healthcare Provider Details

I. General information

NPI: 1457579351
Provider Name (Legal Business Name): GARY THOMAS BENNETT MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AMERICAN GREETING RD
CORBIN KY
40701-4811
US

IV. Provider business mailing address

PO BOX 568
CORBIN KY
40702-0568
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: