Provider Demographics
NPI:1902634710
Name:HERAVI, CYRUS
Entity type:Individual
Prefix:
First Name:CYRUS
Middle Name:
Last Name:HERAVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4379
Mailing Address - Country:US
Mailing Address - Phone:949-683-3704
Mailing Address - Fax:
Practice Address - Street 1:1024 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4379
Practice Address - Country:US
Practice Address - Phone:949-683-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95154209163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse