Healthcare Provider Details

I. General information

NPI: 1992965891
Provider Name (Legal Business Name): EVAGRIO PAGKALIWANGAN BENCITO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
CARSON CA
90810-1408
US

IV. Provider business mailing address

3564 BRENTON AVE APT E
LYNWOOD CA
90262-2063
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-3528
  • Fax:
Mailing address:
  • Phone: 310-639-5282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number565369
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number17801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: