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NPI Code Detail

MEDICARE: MR. BENJAMIN MARK V NABONG

MEDICARE: MR. BENJAMIN MARK V NABONG
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
1225200000XPhysical Therapy Assistant

General Provider Information

NPI Number : 1578101820
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BENJAMIN MARK V NABONG
Provider Business Mailing Address
First Line : 17910 MALDEN ST
Second Line :
City : NORTHRIDGE
State : CA
Zip : 91325-3818
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 13400 SHERMAN WAY
Second Line :
City : NORTH HOLLYWOOD
State : CA
Zip : 91605-4415
Country : US
Telephone Number : 818-960-5314
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/17/2019
Last Update Date : 12/17/2019

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