Healthcare Provider Details

I. General information

NPI: 1780978692
Provider Name (Legal Business Name): BENJAMIN MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5935 VAN NUYS BLVD
VAN NUYS CA
91401-3624
US

IV. Provider business mailing address

PO BOX 921015
SYLMAR CA
91392-1015
US

V. Phone/Fax

Practice location:
  • Phone: 818-285-1900
  • Fax: 181-285-1906
Mailing address:
  • Phone: 818-285-1900
  • Fax: 818-285-1906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number071425-II
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: