Healthcare Provider Details

I. General information

NPI: 1437515806
Provider Name (Legal Business Name): CHERYL DE VERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD #600
ENCINO CA
91436-2203
US

IV. Provider business mailing address

3344 COMMUNITY AVE
LA CRESCENTA CA
91214-2554
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1977
  • Fax: 818-986-4752
Mailing address:
  • Phone: 818-357-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberOTA 180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: