Healthcare Provider Details

I. General information

NPI: 1770200230
Provider Name (Legal Business Name): BENJAMIN LEVENTER MSTAM, DAIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 E GREEN ST
PASADENA CA
91101-2117
US

IV. Provider business mailing address

920 W AVENUE 37
LOS ANGELES CA
90065-3240
US

V. Phone/Fax

Practice location:
  • Phone: 626-656-6599
  • Fax:
Mailing address:
  • Phone: 323-437-6702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: