Healthcare Provider Details

I. General information

NPI: 1447190228
Provider Name (Legal Business Name): MATTHEW BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
JEFFERSON LA
70121-2451
US

IV. Provider business mailing address

208 MOSS BAYOU LN
KENNER LA
70065-6602
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-3000
  • Fax:
Mailing address:
  • Phone: 504-273-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: