Healthcare Provider Details

I. General information

NPI: 1104094697
Provider Name (Legal Business Name): LUKE LAZAR BENOIT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 6TH ST
SANTA ANA CA
92703-2101
US

IV. Provider business mailing address

1225 W 6TH ST
SANTA ANA CA
92703-2101
US

V. Phone/Fax

Practice location:
  • Phone: 714-972-1402
  • Fax: 714-972-1519
Mailing address:
  • Phone: 714-972-1402
  • Fax: 714-972-1519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: