Provider Demographics
NPI:1336290873
Name:BENTON, JEFFREY (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BENTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 WILSHIRE BLVD
Mailing Address - Street 2:#210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5603
Mailing Address - Country:US
Mailing Address - Phone:323-297-0566
Mailing Address - Fax:
Practice Address - Street 1:6360 WILSHIRE BLVD
Practice Address - Street 2:#210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5603
Practice Address - Country:US
Practice Address - Phone:323-297-0566
Practice Address - Fax:323-297-0568
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU69856Medicare UPIN
CADC24698Medicare ID - Type Unspecified