MEDICARE: W. BENTON BOONE A PROFESSIONAL CORPORATION

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	G13745	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
2	G13745	OTHER		CA LICENSE
3	W21977	OTHER	CA	GROUP PTAN

General Provider Information

NPI Number	:	1730114257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W. BENTON BOONE A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	8616 LA TIJERA BLVD
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3944
Country	:	US
Telephone Number	:	310-673-2020
Fax Number	:	310-649-5290

Provider Business Practice Location Address
First Line	:	8616 LA TIJERA BLVD
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3944
Country	:	US
Telephone Number	:	310-673-2020
Fax Number	:	310-649-5290

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIE BENTON BOONE
Credential	:	M.D.
Telephone Number	:	310-673-2020

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	02/29/2012

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