Healthcare Provider Details

I. General information

NPI: 1225509995
Provider Name (Legal Business Name): MICHAEL DAVID BERRETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 GREEN VALLEY CIR
CULVER CITY CA
90230-7068
US

IV. Provider business mailing address

3107 SANTA MONICA BLVD APT J
SANTA MONICA CA
90404-2568
US

V. Phone/Fax

Practice location:
  • Phone: 310-846-5270
  • Fax: 310-846-5278
Mailing address:
  • Phone: 310-963-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: