MEDICARE: BENNETT CHIROPRACTIC, INC

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	111N00000X	Chiropractor	2025	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51507154	OTHER	AL	BLUE CROSS/BLUE SHEILD

General Provider Information

NPI Number	:	1710162854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENNETT CHIROPRACTIC, INC

Provider Business Mailing Address
First Line	:	120 W DUBLIN DR
Second Line	:	102
City	:	MADISON
State	:	AL
Zip	:	35758-3155
Country	:	US
Telephone Number	:	256-774-7189
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 W DUBLIN DR
Second Line	:	102
City	:	MADISON
State	:	AL
Zip	:	35758-3155
Country	:	US
Telephone Number	:	256-774-7189
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WALTER CHARLES BENNETT
Credential	:	D.C.
Telephone Number	:	256-774-7189

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	04/18/2008

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