Healthcare Provider Details

I. General information

NPI: 1205117611
Provider Name (Legal Business Name): BRUCE C. BENNETT, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 01/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 E 2ND ST SUITE 100
CASPER WY
82601-2946
US

IV. Provider business mailing address

4531 E 23RD ST
CASPER WY
82609-3285
US

V. Phone/Fax

Practice location:
  • Phone: 307-265-4343
  • Fax:
Mailing address:
  • Phone: 307-439-9088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7871A
License Number StateWY

VIII. Authorized Official

Name: DR. BRUCE BENNETT
Title or Position: SOLE MEMBER
Credential: MD
Phone: 307-439-9088