=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881859346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENTLEY CHIROPRACTIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2008
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 E 20TH ST SUITE 105
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87402-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-564-8555
-----------------------------------------------------
Fax | 505-564-8556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 E 20TH ST SUITE 105
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87402-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-564-8555
-----------------------------------------------------
Fax | 505-564-8556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT T BENTLEY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 505-564-8555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1463
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------