Healthcare Provider Details

I. General information

NPI: 1295269074
Provider Name (Legal Business Name): CHERYL L. BENNETT OD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BUCKHANNON
BUCKHANNON WV
26201-8422
US

IV. Provider business mailing address

28 VIRGINIA AVE
PETERSBURG WV
26847-1740
US

V. Phone/Fax

Practice location:
  • Phone: 304-472-7703
  • Fax: 304-472-8088
Mailing address:
  • Phone: 304-472-7703
  • Fax: 304-472-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number984-IOD
License Number StateWV

VIII. Authorized Official

Name: CHERYL LYN BENNETT
Title or Position: OWNER
Credential: OD
Phone: 304-472-7703