Provider Demographics
NPI:1588872246
Name:DICK, ERIC LAVERNE (MED, ATC)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:LAVERNE
Last Name:DICK
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 YARMOUTH AVE
Mailing Address - Street 2:#111
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2309
Mailing Address - Country:US
Mailing Address - Phone:818-389-7089
Mailing Address - Fax:
Practice Address - Street 1:7500 CHAMINADE AVE
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91304-5384
Practice Address - Country:US
Practice Address - Phone:818-347-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer