Provider Demographics
NPI:1295878601
Name:BERRETH, EDWARD EUGENE (CRTT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:EUGENE
Last Name:BERRETH
Suffix:
Gender:M
Credentials:CRTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93216-0645
Mailing Address - Country:US
Mailing Address - Phone:661-725-7438
Mailing Address - Fax:661-725-5868
Practice Address - Street 1:909 12TH AVE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2255
Practice Address - Country:US
Practice Address - Phone:661-725-7438
Practice Address - Fax:661-725-5868
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100506332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME00042FMedicaid
CA0256940001Medicare NSC