Basic Information
| Provider Information | |||||||||
| NPI: | 1497849392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA BENEST M D A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1624 W OLIVE AVENUE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187299149 | ||||||||
| FaxNumber: | 8187299119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | BENEST | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8187299149 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.