Provider Demographics
NPI:1225761042
Name:BENAVIDES SOLE, MARISA ISABEL
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ISABEL
Last Name:BENAVIDES SOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 WILSHIRE BLVD.
Mailing Address - Street 2:MAILSTOP 53
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3250 WILSHIRE BLVD.
Practice Address - Street 2:MAILSTOP 53
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010
Practice Address - Country:US
Practice Address - Phone:323-361-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program