MEDICARE: MRS. BETH SARA BENNETT MA, OTRL

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	111NX0100X	Occupational Health Chiropractor	0129271	NY

General Provider Information

NPI Number	:	1922366152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BETH SARA BENNETT MA, OTRL

Provider Business Mailing Address
First Line	:	620 CENTRAL AVE
Second Line	:
City	:	CEDARHURST
State	:	NY
Zip	:	11516-2303
Country	:	US
Telephone Number	:	516-569-3083
Fax Number	:	516-374-1185

Provider Business Practice Location Address
First Line	:	620 CENTRAL AVE
Second Line	:
City	:	CEDARHURST
State	:	NY
Zip	:	11516-2303
Country	:	US
Telephone Number	:	516-569-3083
Fax Number	:	516-374-1185

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

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	04/25/2012

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