Healthcare Provider Details

I. General information

NPI: 1104663517
Provider Name (Legal Business Name): ELIZABETH ROSE VERMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10281 KIDD ST
RIVERSIDE CA
92503-3469
US

IV. Provider business mailing address

PO BOX 1341
RIVERSIDE CA
92502-1341
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5050
  • Fax: 951-784-4986
Mailing address:
  • Phone: 951-238-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IVCWKD
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: