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General NPI Number Information
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NPI Number | 1033640586
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Entity Type | Organization
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Legal Business Name | BENNETT CHIROPRACTIC WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 03/27/2017
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Last Update Date | 03/27/2017
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Provider Practice Location Address
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Address Line | 1178 FREMONT CT
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City | ELKHART
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State | IN
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Zip | 46516-9321
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Country | US
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Telephone | 574-238-6199
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Fax |
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Provider Business Mailing Address
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Address Line | 1618 WEAVER WOODS DR
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City | GOSHEN
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State | IN
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Zip | 46526-8142
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Country | US
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Telephone | 574-238-6199
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MATTHEW BENNETT
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Credential |
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Telephone | 574-238-6199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08002949A
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License Number State | IN
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