Healthcare Provider Details

I. General information

NPI: 1811889231
Provider Name (Legal Business Name): NIR LIEBENTHAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

IV. Provider business mailing address

201 N TOLUCA ST APT 16
LOS ANGELES CA
90026-5696
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8921
  • Fax:
Mailing address:
  • Phone: 781-718-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: