1770886426 NPI number — BENNETT CLINIC, PC

Table of content: (NPI 1770886426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770886426 NPI number — BENNETT CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENNETT CLINIC, PC
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:
1770886426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 964
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73932-0964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-625-2273
Provider Business Mailing Address Fax Number:
580-625-2274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 AVENUE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73932-3126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-625-2273
Provider Business Practice Location Address Fax Number:
580-625-2274
Provider Enumeration Date:
12/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER/FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
580-625-2273

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  R0071654 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200317900A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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