Basic Information
| Provider Information | |||||||||
| NPI: | 1679832745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAVARUA MEDICAL REHABILITATION SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TAVARUA MEDICAL & MENTAL 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: | 6265 SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914111114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187790555 | ||||||||
| FaxNumber: | 8187790455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2012 | ||||||||
| LastUpdateDate: | 05/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | STAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 960000644 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QP2300X | 960000644 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.