Healthcare Provider Details

I. General information

NPI: 1053805697
Provider Name (Legal Business Name): DORA HARVISTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W CENTRAL AVE STE B
BREA CA
92821-3036
US

IV. Provider business mailing address

9069 WALKER ST
CYPRESS CA
90630-3161
US

V. Phone/Fax

Practice location:
  • Phone: 714-529-5022
  • Fax: 714-529-5016
Mailing address:
  • Phone: 714-322-8946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: