Healthcare Provider Details

I. General information

NPI: 1023440591
Provider Name (Legal Business Name): MR. RYAN JOSHUA BENTICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21828 S. AVALON BLVD
CARSON CA
90745-3303
US

IV. Provider business mailing address

21828 S. AVALON BLVD
CARSON CA
90745-3303
US

V. Phone/Fax

Practice location:
  • Phone: 424-477-5225
  • Fax:
Mailing address:
  • Phone: 424-477-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: