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General NPI Number Information
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NPI Number | 1104077569
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Entity Type | Organization
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Legal Business Name | PORT MEDICAL WELLNESS, INC.
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Dates
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Enumeration Date | 10/03/2008
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Last Update Date | 10/14/2008
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Provider Practice Location Address
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Address Line | 512 N AVALON BLVD
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City | WILMINGTON
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State | CA
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Zip | 90744-5806
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Country | US
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Telephone | 310-816-2943
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Fax | 310-816-9393
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Provider Business Mailing Address
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Address Line | PO BOX 128 C/O STELLA REDENSKI
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City | PACIFIC PALISADES
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State | CA
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Zip | 90272-0128
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Country | US
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Telephone | 310-522-5811
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. LAURENT RUBEN BENHAMOU
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Credential | D.O.
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Telephone | 310-522-5811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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