Healthcare Provider Details

I. General information

NPI: 1447581350
Provider Name (Legal Business Name): BRENTVIEW MEDICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD GROUND FLOOR
LOS ANGELES CA
90049-5106
US

IV. Provider business mailing address

11611 SAN VICENTE BLVD GROUND FLOOR
LOS ANGELES CA
90049-5106
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-0013
  • Fax: 310-207-2630
Mailing address:
  • Phone: 310-820-0013
  • Fax: 310-207-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAPHAEL DARVISH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 310-826-2555