Healthcare Provider Details

I. General information

NPI: 1548617574
Provider Name (Legal Business Name): DERRICK ANTHONY CHATMAN LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 COUNTY FARM RD
RIVERSIDE CA
92503-3542
US

IV. Provider business mailing address

9990 COUNTY FARM RD
RIVERSIDE CA
92503-3542
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-6031
  • Fax:
Mailing address:
  • Phone: 951-358-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number255725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: