Provider Demographics
NPI:1144832718
Name:PRINE, DEREK
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:PRINE
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 1:1427 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-3456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1427 69TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-3456
Practice Address - Country:US
Practice Address - Phone:209-485-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276992279P1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P1006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Function Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27699OtherCALIFORNIA BOARD OF RESPIRATORY CARE LICENSE