Healthcare Provider Details

I. General information

NPI: 1598965733
Provider Name (Legal Business Name): CAMERON BENNETT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 FAIRWAY ST
GREENVILLE TX
75402-8120
US

IV. Provider business mailing address

2023 FAIRWAY ST
GREENVILLE TX
75402-8120
US

V. Phone/Fax

Practice location:
  • Phone: 603-391-5147
  • Fax: 855-232-8604
Mailing address:
  • Phone: 603-391-5147
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0898
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2081000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: