Healthcare Provider Details

I. General information

NPI: 1770748261
Provider Name (Legal Business Name): CHILD NEUROLOGY OF BEVERLY HILLS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W GLENOAKS BLVD # 705
GLENDALE CA
91202-2896
US

IV. Provider business mailing address

501 W GLENOAKS BLVD # 705
GLENDALE CA
91202-2896
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-7857
  • Fax: 818-788-7857
Mailing address:
  • Phone: 818-788-7857
  • Fax: 818-788-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberA73193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA73193
License Number StateCA

VIII. Authorized Official

Name: DR. MICHELE MARIE VAN HIRTUM-DAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-788-7857