Healthcare Provider Details

I. General information

NPI: 1487140935
Provider Name (Legal Business Name): 90265 MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23661 PACIFIC COAST HIGHWAY
MALIBU CA
90265
US

IV. Provider business mailing address

23661 PACIFIC COAST HIGHWAY
MALIBU CA
90265
US

V. Phone/Fax

Practice location:
  • Phone: 310-341-0188
  • Fax: 818-668-3604
Mailing address:
  • Phone: 310-456-1603
  • Fax: 310-456-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA MARIE BENYA
Title or Position: PRESIDENT
Credential: DO
Phone: 310-341-0188