Provider Demographics
NPI:1104077569
Name:PORT MEDICAL WELLNESS, INC.
Entity type:Organization
Organization Name:PORT MEDICAL WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENT
Authorized Official - Middle Name:RUBEN
Authorized Official - Last Name:BENHAMOU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-522-5811
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:C/O STELLA REDENSKI
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-0128
Mailing Address - Country:US
Mailing Address - Phone:310-522-5811
Mailing Address - Fax:
Practice Address - Street 1:512 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5806
Practice Address - Country:US
Practice Address - Phone:310-816-2943
Practice Address - Fax:310-816-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty