Healthcare Provider Details

I. General information

NPI: 1215859103
Provider Name (Legal Business Name): BRIAN ADAM BENAVIDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22312 MARINE VIEW DR S
DES MOINES WA
98198-6832
US

IV. Provider business mailing address

21646 14TH AVE S APT D5
DES MOINES WA
98198-8336
US

V. Phone/Fax

Practice location:
  • Phone: 206-824-8464
  • Fax:
Mailing address:
  • Phone: 202-430-7569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number70001604
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: