Healthcare Provider Details

I. General information

NPI: 1043957822
Provider Name (Legal Business Name): MRS. LARRISSA EVETTE BENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S BROADWAY
LOS ANGELES CA
90013-1102
US

IV. Provider business mailing address

425 S BROADWAY
LOS ANGELES CA
90013-1102
US

V. Phone/Fax

Practice location:
  • Phone: 213-213-0100
  • Fax:
Mailing address:
  • Phone: 213-213-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: