Healthcare Provider Details

I. General information

NPI: 1366269581
Provider Name (Legal Business Name): LARRY BENTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 W WASHINGTON BLVD
LOS ANGELES CA
90016-1331
US

IV. Provider business mailing address

2644 30TH ST STE 100
SANTA MONICA CA
90405-3051
US

V. Phone/Fax

Practice location:
  • Phone: 323-287-2023
  • Fax:
Mailing address:
  • Phone: 310-314-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number0013819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: