Provider Demographics
NPI:1376761940
Name:BENEVOLENCE INDUSTRIES INCORPORATED
Entity Type:Organization
Organization Name:BENEVOLENCE INDUSTRIES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KWABENA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-800-7963
Mailing Address - Street 1:3533 W. PICO BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:323-734-1600
Mailing Address - Fax:323-734-1666
Practice Address - Street 1:3533 W. PICO BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019
Practice Address - Country:US
Practice Address - Phone:323-734-1600
Practice Address - Fax:323-734-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-21
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QF0400X
CA550001067261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376761940Medicaid
CAW21010Medicare UPIN