Healthcare Provider Details

I. General information

NPI: 1790087435
Provider Name (Legal Business Name): BERVICK DECULUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 W JEFFERSON BLVD
LOS ANGELES CA
90018-3230
US

IV. Provider business mailing address

3210 W JEFFERSON BLVD
LOS ANGELES CA
90018-3230
US

V. Phone/Fax

Practice location:
  • Phone: 323-731-4981
  • Fax: 323-731-4958
Mailing address:
  • Phone: 323-731-4981
  • Fax: 323-731-4958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: