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General NPI Number Information
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NPI Number | 1134158538
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Entity Type | Individual
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Provider Name | MARY W BENNETT ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 101 HARRIS INDUSTRIAL BLVD
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City | VIDALIA
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State | GA
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Zip | 30474-8845
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Country | US
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Telephone | 912-277-2035
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Fax |
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Provider Business Mailing Address
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Address Line | 707 LOOP RD APT 2D
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City | VIDALIA
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State | GA
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Zip | 30474-8535
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Country | US
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Telephone | 912-277-2035
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001249
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License Number State | GA
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