Healthcare Provider Details

I. General information

NPI: 1093354573
Provider Name (Legal Business Name): KEITH BENTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 BORDER AVE
TORRANCE CA
90501-3606
US

IV. Provider business mailing address

127 E 30TH ST APT 16B
NEW YORK NY
10016-7381
US

V. Phone/Fax

Practice location:
  • Phone: 844-443-6246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: