1770003766 NPI number — HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.

Table of content: (NPI 1770003766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770003766 NPI number — HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARBOR VILLAGE DETOXIFICATION AND REHABILITATION INC.
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:
Provider Other Organization Name Type Code:
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:
1770003766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5787 LITTLE SHAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92336-4593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-904-7003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 EL TRAVESIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA HABRA HEIGHTS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90631-8002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-904-7003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHUA
Authorized Official First Name:
MARIA CATHERINE
Authorized Official Middle Name:
KOH
Authorized Official Title or Position:
DIRECTOR / LICENSE MANAGER
Authorized Official Telephone Number:
909-904-7003

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C4033816 . This is a "CALIFORNIA SECRETARY OF STATE REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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