Basic Information
| Provider Information | |||||||||
| NPI: | 1558709121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2963 W WHITE MOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859296257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285375437 | ||||||||
| FaxNumber: | 9285375857 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 ADDISON AVE E STE B | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148000 | ||||||||
| FaxNumber: | 2089339301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11017199A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.