MEDICARE: CARISSA DARLENE BENNETT AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	AU759	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104869551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA DARLENE BENNETT AUD

Provider Business Mailing Address
First Line	:	11645 WILSHIRE BLVD
Second Line	:	SUITE # 600
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1708
Country	:	US
Telephone Number	:	310-477-5558
Fax Number	:	310-477-7281

Provider Business Practice Location Address
First Line	:	11645 WILSHIRE BLVD
Second Line	:	SUITE # 600
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1708
Country	:	US
Telephone Number	:	310-477-5558
Fax Number	:	310-477-7281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	01/28/2009

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Directions to “ CARISSA DARLENE BENNETT AUD” Practice Location

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