Provider Demographics
NPI:1760271662
Name:BIVENS, COURLETT
Entity type:Individual
Prefix:
First Name:COURLETT
Middle Name:
Last Name:BIVENS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 S ANITA DR STE 102-104
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3355
Mailing Address - Country:US
Mailing Address - Phone:714-410-3505
Mailing Address - Fax:
Practice Address - Street 1:265 S ANITA DR STE 102-104
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3355
Practice Address - Country:US
Practice Address - Phone:714-410-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235505164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse