Provider Demographics
NPI:1407988660
Name:UNIVERSITE DU BENIN MEDICAL GROUP, INC.,
Entity Type:Organization
Organization Name:UNIVERSITE DU BENIN MEDICAL GROUP, INC.,
Other - Org Name:UNIVERSITE DU BENIN MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIANSI
Authorized Official - Middle Name:
Authorized Official - Last Name:BONI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-486-9100
Mailing Address - Street 1:PO BOX 6299
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504
Mailing Address - Country:US
Mailing Address - Phone:805-486-9100
Mailing Address - Fax:805-486-7330
Practice Address - Street 1:650 HOBSON WAY # 204
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-6711
Practice Address - Country:US
Practice Address - Phone:805-486-9100
Practice Address - Fax:805-486-7330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45536207LP2900X, 207Q00000X, 208000000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A455360Medicaid
CAW18880Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAG04251Medicare UPIN