Healthcare Provider Details

I. General information

NPI: 1972045110
Provider Name (Legal Business Name): ANTHONY BUTCH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 GRANVILLE AVE
LOS ANGELES CA
90095-6106
US

IV. Provider business mailing address

2122 GRANVILLE AVE
LOS ANGELES CA
90095-6106
US

V. Phone/Fax

Practice location:
  • Phone: 310-312-1509
  • Fax: 310-206-9077
Mailing address:
  • Phone: 310-312-1509
  • Fax: 310-206-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberDRH 091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: