Basic Information
| Provider Information | |||||||||
| NPI: | 1922382324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | ZACHERY | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 343 WALLER AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594758407 | ||||||||
| FaxNumber: | 8592726893 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 WALLER AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405042912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594758407 | ||||||||
| FaxNumber: | 8592726893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 30608012 | 05 | KY | MEDICAID |