1407040603 NPI number — MR. ERIC DARNELL DEVERS MHRS

Table of content: MR. ERIC DARNELL DEVERS MHRS (NPI 1407040603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407040603 NPI number — MR. ERIC DARNELL DEVERS MHRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVERS
Provider First Name:
ERIC
Provider Middle Name:
DARNELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MHRS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407040603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2523 EL PORTAL DR
Provider Second Line Business Mailing Address:
#103
Provider Business Mailing Address City Name:
SAN PABLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94806-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-374-7500
Provider Business Mailing Address Fax Number:
510-374-7504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
248 15TH ST
Provider Second Line Business Practice Location Address:
#22
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94801-3273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-776-0360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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