Healthcare Provider Details

I. General information

NPI: 1639002660
Provider Name (Legal Business Name): ITZEL TAVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 ROCKWOOD AVE STE 102
CALEXICO CA
92231-4408
US

IV. Provider business mailing address

1112 OBELISCOS ST
CALEXICO CA
92231-1956
US

V. Phone/Fax

Practice location:
  • Phone: 760-768-3422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: