MEDICARE: MR. BENJAMIN KERNEVES RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT294231	CA

General Provider Information

NPI Number	:	1841799400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN KERNEVES RPT

Provider Business Mailing Address
First Line	:	12655 W JEFFERSON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7008
Country	:	US
Telephone Number	:	424-285-0443
Fax Number	:	888-859-0145

Provider Business Practice Location Address
First Line	:	3637 CLARINGTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034
Country	:	US
Telephone Number	:	323-963-4401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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