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General NPI Number Information
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NPI Number | 1104167444
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Entity Type | Organization
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Legal Business Name | BENNETT CLINIC LLC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 7876 E FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-2216
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Country | US
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Telephone | 928-772-7200
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Fax | 928-772-7779
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Provider Business Mailing Address
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Address Line | 7876 E FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-2216
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Country | US
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Telephone | 928-772-7200
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Fax | 928-772-7779
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Authorized Official
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Title or Position | PARTNER
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Name | MRS. MARY EVELYN BENNETT
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Credential | R.N.
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Telephone | 928-772-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT 6078
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License Number State | AZ
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