Basic Information
| Provider Information | |||||||||
| NPI: | 1245610344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNALLACK | ||||||||
| FirstName: | GUY | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E CHURCH ST BLDG 8 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393374 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 E CHURCH ST BLDG 8 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393561 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | S3795 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 20A15415 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | XXXXXXXXXX | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | S3795 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.