1184990814 NPI number — TAVARUA MEDICAL REHABILITATION SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184990814 NPI number — TAVARUA MEDICAL REHABILITATION SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAVARUA MEDICAL REHABILITATION SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AZUSA MEDICAL AND MENTAL HEALTH SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184990814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26460 SUMMIT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CLARITA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91350-2991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-254-6630
Provider Business Mailing Address Fax Number:
661-254-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
474 S CITRUS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AZUSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91702-4733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-858-9500
Provider Business Practice Location Address Fax Number:
626-858-9090
Provider Enumeration Date:
03/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BLANKS
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
661-254-6630

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 19-126 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19CQ , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19-126 . This is a "STATE NTP LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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