MEDICARE: LESLIE BENNETT

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	101Y00000X	Counselor
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1639321409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE BENNETT

Provider Business Mailing Address
First Line	:	2700 NW STEWART PKWY
Second Line	:	ANNEX A
City	:	ROSEBURG
State	:	OR
Zip	:	97471-1281
Country	:	US
Telephone Number	:	541-672-5667
Fax Number	:	541-672-1048

Provider Business Practice Location Address
First Line	:	272 NW MEDICAL LOOP STE C
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-5545
Country	:	US
Telephone Number	:	541-440-3532
Fax Number	:	541-440-3554

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

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	07/21/2022

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Directions to “ LESLIE BENNETT ” Practice Location

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