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General NPI Number Information
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NPI Number | 1730114257
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Entity Type | Organization
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Legal Business Name | W. BENTON BOONE A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 02/29/2012
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Provider Practice Location Address
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Address Line | 8616 LA TIJERA BLVD SUITE 102
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City | LOS ANGELES
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State | CA
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Zip | 90045-3944
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Country | US
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Telephone | 310-673-2020
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Fax | 310-649-5290
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Provider Business Mailing Address
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Address Line | 8616 LA TIJERA BLVD SUITE 102
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City | LOS ANGELES
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State | CA
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Zip | 90045-3944
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Country | US
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Telephone | 310-673-2020
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Fax | 310-649-5290
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WILLIE BENTON BOONE
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Credential | M.D.
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Telephone | 310-673-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G13745
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License Number State | CA
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