Healthcare Provider Details

I. General information

NPI: 1740489426
Provider Name (Legal Business Name): ROBERT TELFORD BENNETT B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E PIERCE ST
MANGUM OK
73554-4295
US

IV. Provider business mailing address

3809 HERITAGE TRL
ALTUS OK
73521-1047
US

V. Phone/Fax

Practice location:
  • Phone: 866-926-6552
  • Fax: 580-547-4076
Mailing address:
  • Phone: 580-481-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: