Basic Information
| Provider Information | |||||||||
| NPI: | 1184990814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAVARUA MEDICAL REHABILITATION SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AZUSA MEDICAL AND MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 S CITRUS AVE | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917024733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268589500 | ||||||||
| FaxNumber: | 6268589090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | PRAMESH | ||||||||
| AuthorizedOfficialMiddleName: | PRAKASH | ||||||||
| AuthorizedOfficialTitleorPosition: | SR V P | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 19-126 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 19CQ | 05 | CA | MEDICAID | 19-126 | 01 | CA | STATE NTP LICENSE | OTHER |