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General NPI Number Information
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NPI Number | 1992930994
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Entity Type | Organization
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Legal Business Name | WARREN BANTA MD, A MEDICAL CORPORATION
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 875 N WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-3759
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Country | US
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Telephone | 323-461-0777
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Fax |
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Provider Business Mailing Address
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Address Line | 875 N WESTERN AVE
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City | LOS ANGELES
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State | CA
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Zip | 90029-3759
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Country | US
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Telephone | 323-461-0777
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | WARREN BANTA
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Credential | MD
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Telephone | 323-229-9471
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | A88514
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License Number State | CA
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