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Organization
W. BENTON BOONE A PROFESSIONAL CORPORATION
Active
Organization
W. BENTON BOONE A PROFESSIONAL CORPORATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WILLIE BENTON BOONE M.D. (PRESIDENT)
(310) 673-2020
Entity
Organization
Contact information
Practice address
8616 LA TIJERA BLVD, SUITE 102, LOS ANGELES, CA 90045-3944
(310) 673-2020
(310) 649-5290
Mailing address
8616 LA TIJERA BLVD, SUITE 102, LOS ANGELES, CA 90045-3944
(310) 673-2020
(310) 649-5290
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G13745
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G137450
—
CA
01
—
G13745
CA LICENSE
—
01
—
W21977
GROUP PTAN
CA
Enumeration date
07/12/2006
Last updated
02/29/2012
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