Healthcare Provider Details

I. General information

NPI: 1487386488
Provider Name (Legal Business Name): MEDIVERSE MEDICAL NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S UNION ST UNIT 1082
ANAHEIM CA
92805-7430
US

IV. Provider business mailing address

1910 S UNION ST UNIT 1082
ANAHEIM CA
92805-7430
US

V. Phone/Fax

Practice location:
  • Phone: 818-626-4883
  • Fax:
Mailing address:
  • Phone: 818-626-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRISTINA ENRIQUEZ
Title or Position: PRESIDENT
Credential:
Phone: 818-626-4883