1093896029 NPI number — LARRY BENNETT MEDICAL L L C

Table of content: (NPI 1093896029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093896029 NPI number — LARRY BENNETT MEDICAL L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY BENNETT MEDICAL L L C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093896029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 W BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48858-2576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-773-4433
Provider Business Mailing Address Fax Number:
989-772-9522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 W BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48858-2576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-773-4433
Provider Business Practice Location Address Fax Number:
989-772-9522
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-773-4433

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1093896029 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1103710492 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com