Healthcare Provider Details

I. General information

NPI: 1912446675
Provider Name (Legal Business Name): PATRICK BUENAVENTURA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 S SAN VICENTE BLVD SUITE 100
LOS ANGELES CA
90048-4108
US

IV. Provider business mailing address

5938 WILLOUGHBY AVE
LOS ANGELES CA
90038-3812
US

V. Phone/Fax

Practice location:
  • Phone: 310-360-6780
  • Fax:
Mailing address:
  • Phone: 714-873-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA9945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: