Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1053510321 |
---|---|
Provider Name | Kenny Benjamin |
First Address | Los Angeles, CA 90066-6124 |
Second Address | S Pasadena, CA 91030-4511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2007 |
Last Update Date | 23/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7184 | MEDI-CAL (01) | CA |
7368 | MEDI-CAL (01) | CA |
7667 | MEDI-CAL (01) | CA |
7708 | MEDI-CAL (01) | CA |