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General NPI Number Information
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NPI Number | 1578101820
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Entity Type | Individual
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Provider Name | MR. BENJAMIN MARK V NABONG
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Gender | Male
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Dates
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Enumeration Date | 12/17/2019
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Last Update Date | 12/17/2019
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Provider Practice Location Address
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Address Line | 13400 SHERMAN WAY
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91605-4415
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Country | US
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Telephone | 818-960-5314
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Fax |
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Provider Business Mailing Address
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Address Line | 17910 MALDEN ST
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City | NORTHRIDGE
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State | CA
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Zip | 91325-3818
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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