Provider Demographics
NPI:1487386488
Name:MEDIVERSE MEDICAL NETWORK
Entity type:Organization
Organization Name:MEDIVERSE MEDICAL NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-626-4883
Mailing Address - Street 1:1910 S UNION ST UNIT 1082
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-7430
Mailing Address - Country:US
Mailing Address - Phone:818-626-4883
Mailing Address - Fax:
Practice Address - Street 1:1910 S UNION ST UNIT 1082
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-7430
Practice Address - Country:US
Practice Address - Phone:818-626-4883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty