MEDICARE: DR. LUCKY BENNETT ND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175F00000X	Naturopath	NP-0012	DC
2	175F00000X	Naturopath	NT 60059890	WA

General Provider Information

NPI Number	:	1437482262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCKY BENNETT ND

Provider Business Mailing Address
First Line	:	2201 MOUNT VERNON AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1313
Country	:	US
Telephone Number	:	571-228-9718
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 MOUNT VERNON AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1313
Country	:	US
Telephone Number	:	571-228-9718
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	09/11/2009

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