Healthcare Provider Details

I. General information

NPI: 1154818649
Provider Name (Legal Business Name): DAVID THOMAS BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HIGHLAND AVE
CIRCLEVILLE OH
43113-1208
US

IV. Provider business mailing address

110 HIGHLAND AVE
CIRCLEVILLE OH
43113-1208
US

V. Phone/Fax

Practice location:
  • Phone: 740-215-8024
  • Fax:
Mailing address:
  • Phone: 740-477-1745
  • Fax: 740-477-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberCDCA.165994
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: