Provider Demographics
NPI:1285108241
Name:MINVERVAS MULTIDISCIPLINARY HEALTH SOLUTIONS LLC
Entity type:Organization
Organization Name:MINVERVAS MULTIDISCIPLINARY HEALTH SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERRETTA
Authorized Official - Middle Name:LACHELL
Authorized Official - Last Name:PICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:310-709-6284
Mailing Address - Street 1:2941 STONECREST LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2472
Mailing Address - Country:US
Mailing Address - Phone:310-709-6284
Mailing Address - Fax:
Practice Address - Street 1:2941 STONECREST LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2472
Practice Address - Country:US
Practice Address - Phone:310-709-6284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty