Healthcare Provider Details

I. General information

NPI: 1063240158
Provider Name (Legal Business Name): DYLAN PRESLEY BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENWOOD RD
SHREVEPORT LA
71103-3908
US

IV. Provider business mailing address

534 COLUMBIA ST
SHREVEPORT LA
71104-3240
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4000
  • Fax:
Mailing address:
  • Phone: 318-581-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number208956
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: