Healthcare Provider Details

I. General information

NPI: 1669211207
Provider Name (Legal Business Name): THRIVE HEALTH IV CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 SAN MIGUEL DR STE 206
NEWPORT BEACH CA
92660-7810
US

IV. Provider business mailing address

9675 BRIGHTON WAY STE 410
BEVERLY HILLS CA
90210-5192
US

V. Phone/Fax

Practice location:
  • Phone: 310-636-8757
  • Fax: 310-636-8758
Mailing address:
  • Phone: 310-636-8757
  • Fax: 310-363-8758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND S DOUGLAS
Title or Position: PRESIDENT
Credential: MD
Phone: 310-657-4302