Healthcare Provider Details

I. General information

NPI: 1699453100
Provider Name (Legal Business Name): MR. MAURICE RALPH BARNETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

IV. Provider business mailing address

4203 EDGEHILL DR APT 2
LOS ANGELES CA
90008-4554
US

V. Phone/Fax

Practice location:
  • Phone: 424-368-3456
  • Fax:
Mailing address:
  • Phone: 424-368-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: